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Purswani JM, Goldberg E, Cahlon O, Schnabel F, Axelrod D, Guth A, Perez CA, Shaikh F, Tam M, Formenti SC, Reig B, Gerber NK. A Radiation Therapy Contouring Atlas for Delineation of the Level I and II Axillae in the Prone Position: A Single-Institution Experience. Pract Radiat Oncol 2024:S1879-8500(24)00097-3. [PMID: 38729261 DOI: 10.1016/j.prro.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 04/09/2024] [Accepted: 04/20/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE With transition from supine to prone position, tenting of the pectoralis major occurs, displacing the muscle from the chest wall and shifting the level I and II axillary spaces. For patients for whom we aim to treat the level I and II axillae using the prone technique, accurate delineation of these nodal regions is necessary. Although different consensus guidelines exist for delineation of nodal anatomy in supine position, to our knowledge, there are no contouring guidelines in the prone position that account for this change in nodal anatomy. METHODS AND MATERIALS The level I and II nodal contours from the Radiation Therapy Oncology Group (RTOG) breast cancer supine atlas were adapted for prone position by 2 radiation oncologists and a breast radiologist based on anatomic changes observed from supine to prone positioning on preoperative diagnostic imaging. Forty-three patients from a single institution treated with prone high tangents from 2012 to 2018 were identified as representative cases to delineate the revised level I and II axillae on noncontrast computed tomography (CT) scans obtained during radiation simulation. The revised nodal contours were reviewed by an expanded expert multidisciplinary panel including breast radiologists, radiation oncologists, and surgical oncologists for consistency and reproducibility. RESULTS Consensus was achieved among the panel in order to create modifications from the RTOG breast atlas for CT-based contouring of the level I and II axillae in prone position using bone, muscle, and skin as landmarks. This atlas provides representative examples and accompanying descriptions for the changes described to the caudal and anterior borders of level II and the anterior, posterior, medial, and lateral borders of level I. A step-by-step guide is provided for properly identifying the revised anterior border of the level I axilla. CONCLUSIONS The adaptations to the RTOG breast cancer atlas for prone positioning will enable radiation oncologists to more accurately target the level I and II axillae when the axillae are targets in addition to the breast.
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Colangelo NW, Gerber NK, Vatner RE, Cooper BT. Harnessing the cGAS-STING pathway to potentiate radiation therapy: current approaches and future directions. Front Pharmacol 2024; 15:1383000. [PMID: 38659582 PMCID: PMC11039815 DOI: 10.3389/fphar.2024.1383000] [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: 02/06/2024] [Accepted: 03/15/2024] [Indexed: 04/26/2024] Open
Abstract
In this review, we cover the current understanding of how radiation therapy, which uses ionizing radiation to kill cancer cells, mediates an anti-tumor immune response through the cGAS-STING pathway, and how STING agonists might potentiate this. We examine how cGAS-STING signaling mediates the release of inflammatory cytokines in response to nuclear and mitochondrial DNA entering the cytoplasm. The significance of this in the context of cancer is explored, such as in response to cell-damaging therapies and genomic instability. The contribution of the immune and non-immune cells in the tumor microenvironment is considered. This review also discusses the burgeoning understanding of STING signaling that is independent of inflammatory cytokine release and the various mechanisms by which cancer cells can evade STING signaling. We review the available data on how ionizing radiation stimulates cGAS-STING signaling as well as how STING agonists may potentiate the anti-tumor immune response induced by ionizing radiation. There is also discussion of how novel radiation modalities may affect cGAS-STING signaling. We conclude with a discussion of ongoing and planned clinical trials combining radiation therapy with STING agonists, and provide insights to consider when planning future clinical trials combining these treatments.
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Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, Coles CE, Gerber NK, Kathpal M, Kim L, Laronga C, Meattini I, Nichols EM, Pierce LJ, Poppe MM, Spears PA, Vinayak S, Whelan T, Lyons JA. Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:112-132. [PMID: 37977261 DOI: 10.1016/j.prro.2023.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. METHODS ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns. CONCLUSIONS Based on published data, the ASTRO task force has proposed recommendations to inform best clinical practices on the use of PBI.
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Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, Coles CE, Gerber NK, Kathpal M, Kim L, Laronga C, Meattini I, Nichols EM, Pierce LJ, Poppe MM, Spears PA, Vinayak S, Whelan T, Lyons JA. Publisher's Note to Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline (Pract Radiat Oncol. 2024;14:xxx-xxx. Epub ahead of print November 14, 2023.). Pract Radiat Oncol 2023:S1879-8500(23)00301-6. [PMID: 37984712 DOI: 10.1016/j.prro.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
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Purswani J, Maisonet OG, Xiao J, Teruel JR, Hitchen C, Li X, Goldberg J, Perez CA, Formenti SC, Gerber NK. Phase I-II Study of Prone Hypofractionated Accelerated Breast and Nodal Intensity Modulated Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e201. [PMID: 37784853 DOI: 10.1016/j.ijrobp.2023.06.1078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) In patients (pts) with breast cancer, prone radiation therapy (RT) has been shown to reduce heart and lung dose which may decrease late toxicity. Routinely used for whole breast irradiation, its use to treat regional lymph nodes (LNs) is not widespread. MATERIALS/METHODS In this phase I-II study, pts treated with partial mastectomy or mastectomy with 1-5 pathologically involved LNs underwent whole breast or post-mastectomy RT plus regional nodal irradiation using IMRT to the supraclavicular and level III axillary LNs. Pts who underwent sentinel LN biopsy (SLNB) alone (no axillary dissection) had the level I and II axillary LNs included in the RT field. 40.5Gy in 15 daily 2.7Gy fractions with daily concomitant 0.5Gy tumor bed boost was prescribed. Normal tissue dose constraints included heart V5Gy<5%, ipsilateral lung V10Gy<20%, contralateral lung V5Gy<15%, ipsilateral brachial plexus (BP) maximal dose (Dmax)<43Gy, spinal cord Dmax≤37.5Gy, spinal cord + 0.5cm Dmax<41Gy, thyroid contralateral lobe Dmax<16Gy, esophagus V30Gy<50% and Dmax≤40.5Gy. The primary endpoints were dosimetric feasibility and incidence of >grade 2 acute toxicity according to CTCAE, v3.0. The secondary endpoint was late toxicity. Exploratory outcomes were local recurrence, disease free survival (DFS), and overall survival (OS). RESULTS Between January 2011 to December 2016, 97 pts with stage IB-IIA breast cancer were enrolled. 66 pts underwent partial mastectomy and 31 pts underwent mastectomy. 16 pts had SLNB alone. 33% (95% CI: 23.8%, 43.3%) met all protocol dose constraints. Heart, contralateral lung, spinal cord and esophagus V30Gy constraints were met by all pts. The ipsilateral lung constraint was met in 95% (95% CI: 88.6%, 98.4%) of plans with a mean V10Gy of 9.44% (SD: 6.08). The BP Dmax constraint was exceeded in 31.6% (95% CI: 22.4%, 41.9%) of plans with a mean increase of 2.86 Gy (SD: 7.92 Gy) over target. The esophageal Dmax<40.5Gy constraint was exceeded in 6 plans with an increase in 0.74 Gy (SD: 0.46 Gy) over target. There were no grade 3 acute toxicities meeting the primary toxicity endpoint. Common acute low-grade toxicities by pt included fatigue (grade 1: 54 [56%]; grade 2: 2 [2%]), esophagitis (grade 1: 8 [8%]; grade 2: 2 [2%]), dermatitis (grade 1: 81 [84%]; grade 2: 6 [6%]). At median and maximum follow up of 8.02 (IQR: 3.31) and 13.3 years, respectively, there were 2 local recurrences (2.1%). DFS and OS were 86.6% (95% CI: 78.2%, 92.7%) and 90.7% (95% CI: 83.1%, 95.7%), respectively. The incidence of pts with maximum grade 1, 2 and 3 late toxicities were 39 (40%), 14 (14%), and 2 (2%), respectively. The maximum grade late toxicities included 1 grade 3 retraction and 2 grade 3 asymmetries. There was no brachial plexopathy or pneumonitis. CONCLUSION Patients treated with prone hypofractionated hybrid breast/chest wall tangents and IMRT to the regional LNs demonstrate excellent dosimetry to the heart, lungs and spinal cord, minimal acute and late toxicity and excellent clinical outcomes. PMID: 26723552.
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Purswani J, Goldberg E, Cahlon O, Schnabel F, Axelrod D, Guth A, Perez CA, Shaikh F, Tam M, Formenti SC, Reig B, Gerber NK. A Radiation Therapy Contouring Atlas for Delineation of the Level I-II Axilla in the Prone Position. Int J Radiat Oncol Biol Phys 2023; 117:e200. [PMID: 37784852 DOI: 10.1016/j.ijrobp.2023.06.1077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) When patients are treated prone for whole breast irradiation (WBI), the axilla typically receives less dose than when patients are treated with WBI in the supine position. There are situations, however, where the axilla is a target as in a situation where the physician intends to treat with "high tangents" to provide good coverage of both the breast and level I-II axilla. In these scenarios, ideal target delineation when the patient is in the prone position is not well-defined. While different consensus guidelines exist for delineation of the nodal areas in the supine position, to our knowledge there are no contouring guidelines for the regional nodes in the prone position based on bone, skin, vascular and muscle landmarks. MATERIALS/METHODS Forty-three patients treated with high tangents in the prone position from 2012-2018 were identified as representative cases. The level I and II regional nodal contours from the Radiation Therapy Oncology Group (RTOG) breast cancer atlas were adapted for prone position by a radiation oncologist and a breast radiologist based on anatomic considerations and changes observed from supine to prone positioning on diagnostic imaging. The revised nodal contours were reviewed by an expanded expert multidisciplinary panel including additional breast radiation oncologists and surgical oncologists to delineate the level I and II axilla on noncontrast computed tomography (CT) scans. RESULTS We adapted the RTOG breast cancer atlas, supported by detailed figures, in order to create a CT based atlas of the level I and II axillary lymph node stations in the prone position. For the level I axilla, the cranial and caudal anatomic boundaries remain unchanged. With transition to the prone position from supine, tenting of the pectoralis major occurs displacing the muscle from the chest wall and shifting the axillary space anteromedial to the lateral border of the pectoralis major. Therefore, the anterior boundary is now defined by the plane of the anterior extent of the pectoralis major to skin. The medial boundary is defined by the plane of the lateral border of the pectoralis major and pectoralis minor including to ribs and intercostal muscles. The lateral boundary is defined by the skin, cropped by 5mm. The posterior boundary is defined by the plane of the anterior surface of the latissimus dorsi and subscapularis muscle to skin. For the level II axilla, the cranial, posterior, medial and lateral boundaries remain unchanged. With transition from supine to prone, the axilla exhibits an anterolateral shift, now laterally abutting the lateral border of the pectoralis minor. The anterior boundary is now defined as the posterior aspect of the pectoralis major muscle. The caudal boundary is where the pectoralis minor inserts into ribs. CONCLUSION The adaptations to the RTOG breast cancer atlas for prone positioning will enable radiation oncologists to more accurately target the level I and II axilla when treating patients prone in whom the axilla is a target in addition to the breast.
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Abeloos CH, Xiao J, Oh C, Barbee D, Shah BA, Maisonet OG, Perez CA, Adams S, Schnabel F, Axelrod D, Guth A, Karp N, Gerber NK. Effectiveness and Toxicity of Five Fraction Prone Accelerated Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2023; 117:S47. [PMID: 37784507 DOI: 10.1016/j.ijrobp.2023.06.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Accelerated partial breast irradiation (APBI) after breast conserving therapy (BCT) is increasingly used to treat women with early stage breast cancer. Our institution was an early adopter of 5-fraction ABPI and delivers APBI primarily to patients in the prone position. This study reports long term oncologic and cosmetic outcome in a large cohort of women treated with 5-fraction external beam APBI. MATERIALS/METHODS We included patients receiving APBI 600 cGy × 5 fx delivered every other day or every day between 2010 and 2022. Late toxicities and clinician and patient rated cosmesis were evaluated for patients with > 6 month follow up. Univariate and multivariate logistic regression models were used to identify clinical and dosimetric factors associated with development of acute and late toxicities, clinician and patient rated cosmesis. All statistical tests were two-sided, and the null hypothesis was rejected for p<0.05. Kaplan Meier methodology was used to calculate overall survival (OS), disease-free survival (DFS) and locoregional recurrence-free survival (LR-RFS). RESULTS Four hundred and forty-two patients received APBI either daily (56%) or every other day (44%). Most of the patients (92%) were treated in the prone position. Average mean heart dose was 23 cGy for left-sided and 11 cGy for right-sided breast cancers. Ipsilateral lung V30% ≤ 30%. At a median follow up of 48 months (range: 5.96 - 155 months), 12 (2.7%) patients developed a local recurrence, 14 (3.2%) patients developed a contralateral breast primary, 10 patients (2.3%) developed a distant metastasis and one patient (0.2%) developed a local recurrence followed by a distant metastasis 1 month later. Out of 258 patients with > 6 month follow up, rates of late grade 1-2 telangiectasia, fibrosis, edema, atrophy and hyperpigmentation were 4%, 18%, 1%, 19% and 7% respectively. There was only one late grade 3 event in a patient who developed significant breast atrophy. The rate of good-excellent physician and patient rated cosmesis was 95% and 89% respectively (N = 256 at median follow up of 80 months). On multivariate logistic regression, patients who did not receive any adjuvant endocrine or chemotherapy were at increased risk of developing a local recurrence. Patients with PR negative disease were at increased risk of distant metastasis. Patient who experienced any grade of acute dermatitis during treatment were at increased risk of any high grade (grade ≥ 2) late adverse event and worse physician rated cosmesis. Daily or every other day treatment did not correlate with worse toxicity or clinical outcomes. Plastic surgery involvement, LVI, EIC, lobular histology, and ER negativity did not correlate with an increased risk of recurrence. Five-year LR-RFS, DFS and OS were 98%, 92.5% and 98.6% respectively. CONCLUSION Five- fraction APBI delivered primarily in the prone position either daily or every other day was effective with low rates of local recurrence, minimal toxicity and excellent cosmetic scores at long term follow up.
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Byun DJ, Liu EK, Maisonet OG, Xiao J, Du KL, Gerber NK. Curietherapy User eXperience Pilot Study: A Novel Augmented Reality Educational Tool during Radiation Oncology Consultation for Patients with Breast Cancer. Int J Radiat Oncol Biol Phys 2023; 117:S19-S20. [PMID: 37784449 DOI: 10.1016/j.ijrobp.2023.06.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Improved communication and knowledge delivery by clinicians at initial consultation may reduce anxiety and psychological burdens associated with cancer treatment. Based on our pilot qualitative study which involved semi-structured interviews of breast cancer patients, we developed Curietherapy User eXperience (CurieUx), an educational tool integrating augmented reality display technology into radiation oncology consultations. MATERIALS/METHODS We developed an interactive 3-dimensional hologram using a frictionless, augmented reality desktop display. Animated modules on patient-specific anatomy (breast, regional lymph nodes, organs-at-risk), linear accelerator, and positioning (prone and breath holding techniques) were created. Patients with newly diagnosed localized breast cancer undergoing radiation oncology treatment were prospectively enrolled in this IRB approved study to evaluate the impact of integrating augmented reality educational tools during radiation therapy consultation (n = 40). Likert scale surveys on anxiety (NIH PROMIS), radiation knowledge, and augmented reality experience (modified IBM technology usability survey) were administered to patients before and after radiation consultation. RESULTS A total of 40 newly diagnosed breast cancer patients were enrolled in this study with a median age of 67 years. Majority were diagnosed with T1-T2N0 (75.0%), followed by Tis (17.5%) and N1+ (7.5%). Of the 36 patients who proceeded with radiation, prone technique was utilized in 83.3% and deep inspiratory breath holding technique in 16.7%. Patients reported decreases in multiple components of anxiety after consultation with the CurieUx platform, including in fearfulness (2.13 vs 1.78, p = 0.003), uneasiness (2.28 vs. 1.82, p = 0.008), nervousness (2.41 vs 2.06, p = 0.005), and tenseness (2.28 vs 1.87, p = 0.004). Patients reported significant increases in radiation knowledge across multiple domains, including treatment machine (2.35 vs 4.7, p<0.001), radiation (2.7 vs 4.58, p<0.001), positioning (2.49 vs 4.68, p<0.001), and confidence (2.4 vs 4.3, p<0.001). An overwhelming majority of patients had positive experiences (4 or 5 on Likert scale) with using the CurieUx hologram display as part of consultation, including its ease of understanding (97%), clarity (93%), comfort (100%), value (97%), and satisfaction (97%). CONCLUSION Curietherapy User eXperience is a valuable educational tool that reduces patient anxiety and promotes radiation knowledge. CurieUx is easily incorporated into the existing radiation oncology consultation practice with the vast majority of patients believing it to be a valuable addition to the consultation process.
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Shah A, Galavis P, Xiao J, Gerber NK. Clinical Outcomes and Setup Reproducibility in Patients Receiving Synchronous Bilateral Breast Radiation in the Prone Position. Int J Radiat Oncol Biol Phys 2023; 117:e205-e206. [PMID: 37784862 DOI: 10.1016/j.ijrobp.2023.06.1088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Standardized radiation therapy (RT) positioning and planning are vital to treat both breasts without excess toxicity in patients with synchronous bilateral breast cancer (SBBC). We studied clinical outcomes and setup reproducibility in patients with SBBC treated in the prone position. MATERIALS/METHODS This is a retrospective study of patients receiving RT for SBBC from 2012-2022 treated in the prone position. Patient demographics, RT dose and field, toxicity, and outcomes were collected. RT planning used gantry and table shifts to avoid entrance/exit through contralateral breast and organs at risk. RT delivery was standardized, with left breast treated first. After 2014, radiographic films were placed during the first 5 fractions to evaluate field overlap. Consistent overlap required re-simulation or re-planning. Positional shifts during setup were collected for patients receiving bilateral whole breast irradiation (WBI) and bilateral partial breast irradiation (PBI). RESULTS A total of 45 patients were treated for SBBC. Median age was 67 years. Median follow-up was 28 months. 35 patients were treated with WBI (1 with low axilla on one side) and 5 with PBI. 5 patients were treated with WBI in one breast and PBI in the other. The most common whole breast dose was 40.5Gy, with a simultaneous integrated boost to the lumpectomy cavity to 48Gy. PBI patients were treated with 30Gy (n = 4) or 40.05Gy (n = 1). 8 patients (17.7%) had acute grade 2 and 1 patient (2%) had acute grade 3 dermatitis. This patient was treated WBI bilaterally and was known to have overlap on GaF. Physician and patient accepted higher toxicity for adequate coverage of bilateral upper inner quadrant tumors. Patients with grade > = 2 dermatitis had bilateral WBI (+/- low axilla) except 1. 6 patients had acute dermatitis in the sternal area (5 were WBI and 1 PBI). Only 2 of these patients had overlap on GaF. Of 20 patients with late toxicity follow-up (> 6 months), 5 (25%) had late grade 1-2 dermatitis. 4 (20%) were treated with WBI (+/-low axilla). 1 patient had both a local and distant recurrence. For setup and treatment delivery, couch shifts recorded for patients treated with bilateral WBI (n = 33) and bilateral PBI (n = 5) were minimal. Mean shifts in nearly all dimensions were limited to sub-centimeter or sub-degree changes, with 2D and cone beam CT (CBCT) imaging. Analysis of GaF showed that only 3 patients (10%) had field overlap. A new plan was created for 1 patient to increase the gap between fields, and for the others, patient and physician accepted overlap for adequate coverage. CONCLUSION To our knowledge, this is the first study examining clinical outcomes and setup reproducibility in patients treated with SBBC in the prone position. This study indicates the feasibility of prone bilateral breast treatment with minimal shifts and overlap on daily treatments. However, we do see a higher number of acute dermatitis in patients treated with bilateral WBI (vs. PBI) and that overlap was not seen on GaF in all patients who developed sternal dermatitis.
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Purswani J, Xiao J, Maisonet OG, Cahlon O, Perez CA, Tattersall I, Adotama P, Gutierrez D, Sulman EP, Goldberg J, Gerber NK. Characterization of Objective Skin Color Changes during and after Breast and Chest Wall Radiotherapy and Correlation with Radiation-Induced Skin Toxicity in Breast Cancer Patients, Including Patients with Skin of Color. Int J Radiat Oncol Biol Phys 2023; 117:e200. [PMID: 37784851 DOI: 10.1016/j.ijrobp.2023.06.1076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Radiation dermatitis (RD) is common among women undergoing breast and chest wall radiotherapy (RT); however, existing scales to assess the severity of RD are subjective and do not account for variability in skin of color (SOC). For instance, the Common Terminology Criteria for Adverse Events (CTCAE) criteria do not include hyperpigmentation in the grading scale. There is data indicating worse RD in African American and Hispanic patients; however, the rate and severity in SOC remains unknown given the lack of data using objective measures of RD. Spectrophotometry is one method to quantify the appearance of color by measuring spectral characteristics without the bias associated with subjective clinical scoring. We present a phase I prospective non-therapeutic clinical trial to objectively define SOC at baseline and evaluate spectrophotometric skin changes during and after breast or chest wall RT in parallel with physician-graded RD using CTCAE criteria. We hypothesize that there will be greater discrepancy between physician graded RD and objective measures of RD in patients with SOC in whom hyperpigmentation will be undercaptured by physician-grading. This is the first study intending to correlate SOC with objective changes after RT as a reliable indicator of RD. We offer a novel system for evaluating RD that is applicable to SOC. MATERIALS/METHODS A total of 60 patients with localized breast cancer (stage 0-III) undergoing conventional whole breast or chest wall RT (50Gy/ 25 fx), hypofractionated whole breast RT (40.5Gy/15 fx) or ultrahypofractionated partial breast RT (6Gy x5), with or without regional nodal RT were enrolled. 3 skin color readouts using the Commission International de l'Eclairage 3D color system (l*, a*, b*) were measured within the radiation field using a spectrophotometer at baseline, once weekly during RT, 10 days post RT, 4 weeks and 12 months post RT. The spectrophotometer is a non-invasive, hand-held device that is used in the clinic room with no additional equipment or setup requirements. Data is automatically exported to a spreadsheet organized by timepoint and patient. The l* axis is a gray scale (0 = black, 100 = white) correlating with skin pigmentation and the a* axis describes red and green values correlating with erythema. The primary objective is to evaluate the changes from baseline in skin color readouts in the quadrant of tumor location during and after RT based on fractionation. The secondary objective is to evaluate changes within and across groups defined by baseline skin color. Exploratory objectives include evaluating the association of baseline color readouts and changes after RT with acute and late grade > 2 clinician-rated skin and subcutaneous tissue effects according to the CTCAE, v5.0, physician graded cosmesis and clinical interventions to treat RD, such as use of topical steroids and oral analgesics. As of January 2023, we have enrolled 100% of the planned patients. RESULTS To be determined. CONCLUSION To be determined. Clinical Study Identifier: S22-00192.
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Hardy Abeloos C, Solan A, Perez CA, Maisonet OG, Cronstein BA, Adler RA, Goldberg J, Gerber NK. A Phase II, Randomized, Double Blind, Placebo Controlled Study of the Safety and Efficacy of a Caffeine-Based Antifibrosis Cream in Patients with Breast Cancer Undergoing Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:e177-e178. [PMID: 37784794 DOI: 10.1016/j.ijrobp.2023.06.1026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Radiation induced fibrosis (RIF) is a common long term adverse event in patients undergoing post-mastectomy radiation therapy (PMRT) which can cause capsular contracture, implant loss, and reconstruction complications in women with implant-based breast reconstruction. At a molecular level, adenosine is a driver of RIF. Preclinical data have shown that pharmacologic blockade of the adenosine A2A Receptor (A2AR) in mice as well as an A2AR knockout mouse model prevented skin fibrosis associated with radiation injury. Caffeine is an A2AR antagonist which has been shown to block the development of hepatic fibrosis in liver disease patients. We present a phase II placebo controlled clinical trial to evaluate whether a caffeine-based cream can prevent RIF and thus reduce the rates of reconstructive complications in patients with tissue expander-based reconstruction requiring PMRT. MATERIALS/METHODS Women ≥ 18 years old with breast carcinoma stage 0-III status post mastectomy with tissue expander-based reconstruction who require PMRT to the chest wall +/- the regional nodes are being enrolled. The target accrual is 60 patients. Boost field to the chest wall, scar and/or nodal region is allowed. Patients with inflammatory breast cancer or those requiring skin bolus are excluded. Prior to starting radiation, patients will be randomized to placebo vs. caffeine cream and they will be instructed to apply the cream twice a day starting on the first day of radiation treatment and continuing daily for the duration of radiation until the removal of tissue expanders. The primary study endpoint is reconstructive complications requiring rehospitalization or reoperation by 2 years post radiation including reconstructive failure with or without reconstruction. A safety endpoint of grade ≥ 2 acute radiation dermatitis will also serve as a co-primary endpoint. Secondary endpoints are wound infection/cellulitis, hematoma, seroma, threatened exposure, wound dehiscence, implant leakage, rupture, and or deflation, and capsular contracture that do not meet criteria for the primary endpoint. Clinician rated cosmesis, local recurrence, regional recurrence, distant metastasis and survival up to 4 years are additional secondary endpoints. Exploratory endpoint includes the use of shear wave elastography (SWE) as a potential tool to quantitatively measure post irradiation fibrosis. Correlative aims include assessing epidermal thickness and fat layer thickness from tissue obtained at time of implant exchange for association with the development of fibrosis. The primary efficacy endpoint will be estimated using Kaplan Meier methods from date of randomization. Treatment comparisons will be based on a 2-sided log rank chi-square test and the hazard ratio will be estimated with 95% confidence intervals. The study started accruing in 12/2019 and is estimated to end by 04/2024. As of January 2023, 67% (40/60 patients) of the planned patients have been enrolled. RESULTS To be determined. CONCLUSION To be determined.
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Liu EK, Fuligni G, Maisonet OG, Xiao J, Du KL, Gerber NK, Byun DJ. Understanding Treatment Anxiety and Utility of Mixed Media Educational Tools in Radiation Oncology Consultation: A Qualitative Study. Int J Radiat Oncol Biol Phys 2023; 117:e247. [PMID: 37784967 DOI: 10.1016/j.ijrobp.2023.06.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Anxiety and adjustment disorders are prevalent in cancer patients, especially at the initiation of treatment, which may be alleviated by improved communication at initial consultation. The purpose of this study is to explore patients' needs in how radiation consultation may improve treatment-related anxiety and the role of multimedia visual tools. MATERIALS/METHODS Eight patients previously treated with partial or whole breast irradiation at our institution were interviewed in a semi-structured manner at a median of 1.54 months (range 0.13 - 12.42) after they completed radiation. Interview questions included expectations prior to consultation, experience of consultation and treatment, and the role of augmented reality or multimedia tools. Two independent reviewers performed an inductive, thematic analysis to generate themes and subthemes (inter-rater reliability = 0.79). RESULTS Four main themes were identified in thematic analysis: information expectations, anxiety, personalized education, and visual aids. Patients described preconceptions of radiation, desire for greater volume of information, importance of repetition from providers, benefit of seeing treatment set-up during simulation, and frustrations with the breath-holding process. Anxiety was related to fear of the unknown, difficulty remembering information when anxious, difficulty asking questions, and ambiguity of information worth worrying about. Patients expressed a desire for personalized education, including accounting for prior health conditions, varying health literacy, preference for individualized presentations, and minimizing extraneous input from those not on the healthcare team. Patients desired visuals during consultation, favored 3D technology over 2D mediums, acknowledged differences in learning style, and preferred an interactive component of patient education done in conjunction with visual tools. CONCLUSION While verbal consultation process provides valuable education regarding radiation treatment, patients continue to experience anxiety attributed to fear of the unknown. Augmenting the standard initial consultation with interactive visual aids, particularly in the form of a 3D medium, may enhance the patient experience at time of consultation. The results of this study will inform the development of a patient educational tool and clinical study named Curie therapy User eXperience (CurieUx) to be used during radiation oncology consultations.
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Purswani JM, Bigham Z, Adotama P, Oh C, Xiao J, Maisonet O, Teruel JR, Gutierrez D, Tattersall IW, Perez CA, Gerber NK. Risk of Radiation Dermatitis in Patients With Skin of Color Who Undergo Radiation to the Breast or Chest Wall With and Without Regional Nodal Irradiation. Int J Radiat Oncol Biol Phys 2023; 117:468-478. [PMID: 37060928 DOI: 10.1016/j.ijrobp.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 04/17/2023]
Abstract
PURPOSE Acute radiation dermatitis (ARD) is common after radiation therapy for breast cancer, with data indicating that ARD may disproportionately affect Black or African American (AA) patients. We evaluated the effect of skin of color (SOC) on physician-reported ARD in patients treated with radiation therapy. METHODS AND MATERIALS We identified patients treated with whole breast or chest wall ± regional nodal irradiation or high tangents using 50 Gy in 25 fractions from 2015 to 2018. Baseline skin pigmentation was assessed using the Fitzpatrick scale (I = light/pale white to VI = black/very dark brown) with SOC defined as Fitzpatrick scale IV to VI. We evaluated associations among SOC, physician-reported ARD, late hyperpigmentation, and use of oral and topical treatments for RD using multivariable models. RESULTS A total of 325 patients met eligibility, of which 40% had SOC (n = 129). On multivariable analysis, Black/AA race and chest wall irradiation had a lower odds of physician-reported grade 2 or 3 ARD (odds ratio [OR], 0.110; 95% confidence interval [CI], 0.030-0.397; P = .001; OR, 0.377; 95% CI, 0.161-0.883; P = .025), whereas skin bolus (OR, 8.029; 95% CI, 3.655-17.635; P = 0) and planning target volume D0.03cc (OR, 1.001; 95% CI, 1.000-1.001; P = .028) were associated with increased odds. On multivariable analysis, SOC (OR, 3.658; 95% CI, 1.236-10.830; P = .019) and skin bolus (OR, 26.786; 95% CI, 4.235-169.432; P = 0) were associated with increased odds of physician-reported late grade 2 or 3 hyperpigmentation. There was less frequent use of topical steroids to treat ARD and more frequent use of oral analgesics in SOC versus non-SOC patients (43% vs 63%, P < .001; 50% vs 38%, P = .05, respectively). CONCLUSIONS Black/AA patients exhibited lower odds of physician-reported ARD. However, we found higher odds of late hyperpigmentation in SOC patients, independent of self-reported race. These findings suggest that ARD may be underdiagnosed in SOC when using the physician-rated scale despite this late evidence of radiation-induced skin toxicity.
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Abeloos CH, Purswani JM, Galavis P, McCarthy A, Hitchen C, Choi JI, Gerber NK. Different Re-Irradiation Techniques after Breast-Conserving Surgery for Recurrent or New Primary Breast Cancer. Curr Oncol 2023; 30:1151-1163. [PMID: 36661737 PMCID: PMC9857440 DOI: 10.3390/curroncol30010088] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/05/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Breast re-irradiation (reRT) after breast-conserving surgery (BCS) using external beam radiation is an increasingly used salvage approach for women presenting with recurrent or new primary breast cancer. However, radiation technique, dose and fractionation as well as eligibility criteria differ between studies. There is also limited data on efficacy and safety of external beam hypofractionation and accelerated partial-breast irradiation (APBI) regimens. This paper reviews existing retrospective and prospective data for breast reRT after BCS, APBI reRT outcomes and delivery at our institution and the need for a randomized controlled trial using shorter courses of radiation to better define patient selection for different reRT fractionation regimens.
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Purswani JM, Nwankwo C, Adotama P, Gutierrez D, Perez CA, Tattersall IW, Gerber NK. Radiation-induced skin changes after breast or chest wall irradiation in patients with breast cancer and skin of color: a systematic review. Clin Breast Cancer 2023; 23:1-14. [PMID: 36335037 DOI: 10.1016/j.clbc.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The purpose of this study is to systematically review data pertaining to breast cancer and radiation-induced skin reactions in patients with skin of color (SOC), as well as data pertaining to objective measurements of skin pigmentation in the assessment of radiation dermatitis (RD). METHODS AND MATERIALS We conducted a systematic review utilizing MEDLINE electronic databases to identify published studies until August 2022. Key inclusion criteria included studies that described RD in breast cancer with data pertaining to skin of color and/or characterization of pigmentation changes after radiation. RESULTS We identified 17 prospective cohort studies, 7 cross-sectional studies, 5 retrospective studies and 4 randomized controlled trials. Prospective cohort and retrospective series demonstrate worse RD in African American (AA) patients using subjective physician-graded scales. There is more limited data in patients representing other non-White racial subgroups with SOC. 2 studies utilize patient reported outcomes and 15 studies utilize objective methods to characterize pigmentation change after radiation. There are no prospective and randomized studies that objectively describe pigmentation changes with radiotherapy in SOC. CONCLUSIONS AA patients appear to have worse RD outcomes, though this is not uniformly observed across all studies. There are no studies that describe objective measures of RD and include baseline skin pigmentation as a variable, limiting the ability to draw uniform conclusions on the rate and impact of RD in SOC. We highlight the importance of objectively characterizing SOC and pigmentation changes before, during and after radiotherapy to understand the incidence and severity of RD in SOC.
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Purswani JM, Hardy-Abeloos C, Perez CA, Kwa MJ, Chadha M, Gerber NK. Radiation in Early-Stage Breast Cancer: Moving beyond an All or Nothing Approach. Curr Oncol 2022; 30:184-195. [PMID: 36661664 PMCID: PMC9858412 DOI: 10.3390/curroncol30010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Radiotherapy omission is increasingly considered for selected patients with early-stage breast cancer. However, with emerging data on the safety and efficacy of radiotherapy de-escalation with partial breast irradiation and accelerated treatment regimens for low-risk breast cancer, it is necessary to move beyond an all-or-nothing approach. Here, we review existing data for radiotherapy omission, including the use of age, tumor subtype, and multigene profiling assays for selecting low-risk patients for whom omission is a reasonable strategy. We review data for de-escalated radiotherapy, including partial breast irradiation and acceleration of treatment time, emphasizing these regimens' decreasing biological and financial toxicities. Lastly, we review evidence of omission of endocrine therapy. We emphasize ongoing research to define patient selection, treatment delivery, and toxicity outcomes for de-escalated adjuvant therapies better and highlight future directions.
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Galavis PE, Abeloos CH, Cheng PC, Hitchen C, McCarthy A, Purswani JM, Shah B, Taneja S, Gerber NK. Accelerated partial breast irradiation in early stage breast cancer. Front Oncol 2022; 12:1049704. [PMID: 36439449 PMCID: PMC9685302 DOI: 10.3389/fonc.2022.1049704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/25/2022] [Indexed: 12/10/2023] Open
Abstract
Accelerated partial breast irradiation (APBI) is increasingly used to treat select patients with early stage breast cancer. However, radiation technique, dose and fractionation as well as eligibility criteria differ between studies. This has led to controversy surrounding appropriate patients for APBI and an assessment of the toxicity and cosmetic outcomes of APBI as compared to whole breast irradiation (WBI). This paper reviews existing data for APBI, APBI delivery at our institution, and ongoing research to better define patient selection, treatment delivery, dosimetric considerations and toxicity outcomes.
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Kim JK, Karp JM, Gerber NK. Regional nodal irradiation (RNI) in breast cancer patients with residual isolated tumor cells or micrometastatic nodal disease after neoadjuvant chemotherapy. Clin Transl Radiat Oncol 2022; 38:195-201. [DOI: 10.1016/j.ctro.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022] Open
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Kim JK, Barry-Walsh B, Russo N, Smith B, Ganey-Aquino S, Concert C, Purswani J, Domogauer J, Perez C, Cooper BT, Gerber NK, Kimmelman A, Evans A. Screening for Vaccination Status and Providing Appropriate COVID-19 Vaccine Education to Radiation Oncology Patients. Int J Radiat Oncol Biol Phys 2022. [PMCID: PMC9366021 DOI: 10.1016/j.ijrobp.2022.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Cooper B, Chmura SJ, Luke JJ, Shiao SL, Basho RK, Iams WT, Page DB, Li C, Gregory RC, Shaw MH, Horn KH, Gibbs JP, Appleman VA, Berger AJ, Abu-Yousif AO, Lineberry NB, Stumpo KF, Elfiky A, Gerber NK. Abstract CT243: Phase 1 study of TAK-676 + pembrolizumab following radiation therapy in patients with advanced non-small-cell lung cancer (NSCLC), triple-negative breast cancer (TNBC), or squamous-cell carcinoma of the head and neck (SCCHN). Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-ct243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Radiation therapy has immune-modulating effects resulting from apoptosis of tumor cells and DNA damage. The downstream generation of cytosolic DNA activates the cyclic GMP-AMP Synthase (cGAS)-STimulator of INterferon Gene (STING) signaling axis in both tumor and nearby immune cells, leading to increased induction of type I interferon (IFN-I) and other immune stimulating molecules. TAK-676 is a novel synthetic STING agonist being investigated (+/- pembrolizumab) in an ongoing first-in-human phase 1 study (NCT04420884). TAK-676 is a potent modulator of the innate immune system and leads to downstream activation of the adaptive immune system to produce antitumor responses in preclinical studies. In contrast to intratumorally injected STING agonists, TAK-676 is optimally designed for reduced serum degradation and enhanced permeability, allowing systemic IV delivery and access to tumor sites and lymphatics. The addition of TAK-676 following radiation therapy may enhance the immune response by increasing the STING-mediated IFN-I release and further stimulate T cell-mediated antitumor immunity, particularly in combination with anti-PD-1/PD-L1 therapies. Impaired IFN signaling has been linked to checkpoint inhibitor (CPI) resistance. Preclinical studies show that addition of a STING agonist may reverse the mechanisms of resistance in tumors with prior exposure to CPIs. This phase 1 trial was designed to investigate the safety and preliminary antitumor activity of TAK-676 + pembrolizumab following radiation therapy (NCT04879849).
Methods: Patients aged ≥18 years with advanced NSCLC, TNBC, or SCCHN who have progressed on CPIs with ≥2 lesions, one of which can be targeted with radiation, are being enrolled. Patients receive 8 Gy x 3 fractions of image-guided radiation therapy followed by (after a minimum of 40 hours) IV pembrolizumab 200 mg on day 1 plus escalating doses of IV TAK-676 on days 1, 8, and 15 of a 21-day cycle. TAK-676 dose escalation is guided by the Bayesian Optimal Interval design. Patients receive TAK-676 + pembrolizumab until disease progression, intolerance, or withdrawal of consent. Once pharmacologically active dose levels of TAK-676 have been observed, paired biopsies will be collected in patients with a safely accessible lesion outside the radiation field at screening and between days 15 and 21 of cycle 1. The primary objective is to determine the safety and tolerability of TAK-676 + pembrolizumab following radiation therapy; secondary objectives are to determine the recommended phase 2 dose of TAK-676 + pembrolizumab following radiation therapy, and to assess preliminary antitumor activity both locally (in the radiation field) and systemically (non-radiated lesions). As of January 2022, nearly 10% of the planned patients have been enrolled.
Citation Format: Benjamin Cooper, Steven J. Chmura, Jason J. Luke, Stephen L. Shiao, Reva K. Basho, Wade T. Iams, David B. Page, Cong Li, Richard C. Gregory, Michael H. Shaw, Kristin H. Horn, John P. Gibbs, Vicky A. Appleman, Allison J. Berger, Adnan O. Abu-Yousif, Neil B. Lineberry, Kate F. Stumpo, Aymen Elfiky, Naamit K. Gerber. Phase 1 study of TAK-676 + pembrolizumab following radiation therapy in patients with advanced non-small-cell lung cancer (NSCLC), triple-negative breast cancer (TNBC), or squamous-cell carcinoma of the head and neck (SCCHN) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT243.
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Modrek AS, Karp JM, Byun D, Gerber NK, Abdul-Hay M, Al-Homsi AS, Galavis P, Teruel J, Yuan Y. Pulmonary toxicity following myeloablative conditioning with total body irradiation delivered via volumetric modulated arc therapy with fludarabine. Pract Radiat Oncol 2022; 12:e476-e480. [DOI: 10.1016/j.prro.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
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Shah C, Bremer T, Cox C, Whitworth P, Patel R, Patel A, Brown E, Gold L, Rock D, Riley L, Kesslering C, Brown S, Gabordi R, Pellicane J, Rabinovich R, Khan S, Templeton S, Majithia L, Willey SC, Wärnberg F, Gerber NK, Shivers S, Vicini FA. The Clinical Utility of DCISionRT ® on Radiation Therapy Decision Making in Patients with Ductal Carcinoma In Situ Following Breast-Conserving Surgery. Ann Surg Oncol 2021; 28:5974-5984. [PMID: 33821346 PMCID: PMC8526470 DOI: 10.1245/s10434-021-09903-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND The role of radiation therapy (RT) following breast-conserving surgery (BCS) in ductal carcinoma in situ (DCIS) remains controversial. Trials have not identified a low-risk cohort, based on clinicopathologic features, who do not benefit from RT. A biosignature (DCISionRT®) that evaluates recurrence risk has been developed and validated. We evaluated the impact of DCISionRT on clinicians' recommendations for adjuvant RT. METHODS The PREDICT study is a prospective, multi-institutional, observational registry in which patients underwent DCISionRT testing. The primary endpoint was to identify the percentage of patients where testing led to a change in RT recommendations. RESULTS Overall, 539 women were included in this study. Pre DCISionRT testing, RT was recommended to 69% of patients; however, post-testing, a change in the RT recommendation was made for 42% of patients compared with the pre-testing recommendation; the percentage of women who were recommended RT decreased by 20%. For women initially recommended not to receive an RT pre-test, 35% had their recommendation changed to add RT following testing, while post-test, 46% of patients had their recommendation changed to omit RT after an initial recommendation for RT. When considered in conjunction with other clinicopathologic factors, the elevated DCISionRT score risk group (DS > 3) had the strongest association with an RT recommendation (odds ratio 43.4) compared with age, grade, size, margin status, and other factors. CONCLUSIONS DCISionRT provided information that significantly changed the recommendations to add or omit RT. Compared with traditional clinicopathologic features used to determine recommendations for or against RT, the factor most strongly associated with RT recommendations was the DCISionRT result, with other factors of importance being patient preference, tumor size, and grade.
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Shah BA, Xiao J, Oh C, Taneja S, Barbee D, Maisonet O, Huppert N, Perez C, Gerber NK. Five-Fraction Prone Accelerated Partial Breast Irradiation: Long-Term Oncologic, Dosimetric, and Cosmetic Outcome. Pract Radiat Oncol 2021; 12:106-112. [PMID: 34474168 DOI: 10.1016/j.prro.2021.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Randomized data support accelerated partial breast irradiation (APBI) for early-stage breast cancer with variable techniques and cosmesis outcomes. We have treated patients with 5-fraction prone external beam APBI for over a decade and herein report acute and late outcomes. METHODS AND MATERIALS Patients receiving APBI 600 cGy × 5 between 2010 and 2019 were included. APBI was primarily delivered prone, with opposed tangents targeting the tumor bed expanded by 1.5 cm (cropped 6 mm from skin). Ipsilateral breast was constrained to V50% < 60% and V100% < 35%. Survival was estimated with Kaplan-Meier. Late toxicities and clinician- and patient-rated cosmesis were evaluated for patients with >6 months follow-up (FU). RESULTS Of 345 patients meeting criteria, 14 were excluded due to APBI given for ipsilateral breast tumor recurrence (IBTR; n = 3), palliation (n = 9), and incomplete radiation therapy course (n = 2). Of the 331 remaining, median age was 70, 7.2% had ductal carcinoma in situ, and 94.3% were treated prone, with 32% treated every other day and 68% on consecutive days. Mean heart dose was 23.8 cGy for left-sided and 12.7 cGy for right-sided cancers. Ipsilateral lung V30% was 0.4%. At 5-year median FU, there were 7 (2.1%) IBTR, 9 (2.7%) contralateral recurrences, and 1 (0.3%) distant metastasis. Five-year local recurrence-free, disease-free, and overall survival was 99.5%, 96.7%, and 98.1%, respectively. When comparing patients with IBTR versus without, a higher proportion did not receive hormone therapy (71.4% vs. 26.2%, P = .018). Rates of acute grade 1 to 2 dermatitis, fatigue, and pain were 35.4%, 21.8%, and 9.4%, respectively, with no grade 3 toxicity. The rate of good-excellent physician- and patient-rated cosmesis (n = 199, median FU 2.8 years) was 92.5% and 89.4%, respectively. Patients experienced low rates of telangiectasia, fibrosis, and retraction/atrophy. CONCLUSIONS We report excellent dosimetric, oncologic, cosmetic, and late toxicity outcomes for patients treated with 5-fraction APBI. To our knowledge this is the largest series of women treated with prone APBI.
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Karp JM, Teruel J, Gerber NK. Early Stage Pregnancy During Radiation Therapy to the Breast. Pract Radiat Oncol 2021; 11:148-151. [PMID: 33676632 DOI: 10.1016/j.prro.2020.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/26/2022]
Abstract
We describe a model case of unplanned pregnancy during radiation therapy to the chest wall and peripheral lymphatics for breast cancer. We use the Morbidity and Mortality Conference format to demonstrate how radiation oncology departments should evaluate and manage this situation.
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Purswani JM, Oh C, Jaros B, Sandigursky S, Xiao J, Gerber NK. Breast Conservation in Women with Autoimmune Disease: The Role of Active Autoimmune Disease and Hypofractionation on Acute and Late Toxicity in a Case-Controlled Series. Int J Radiat Oncol Biol Phys 2021; 110:783-791. [PMID: 33545303 DOI: 10.1016/j.ijrobp.2021.01.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Autoimmune connective tissue disease (CTD) has historically represented a relative contraindication to breast conservation (BC) among patients with early-stage breast cancer. Controversy exists regarding the use of hypofractionated radiation therapy (RT) among patients with CTDs. We evaluated acute and late toxicity in patients with breast cancer and CTD treated with BC. METHODS AND MATERIALS Of 1983 patients treated with BC from 2012 to 2016, we identified 91 patients with an autoimmune disease (AD). Each patient was matched to a control without AD based on age, RT field, and fractionation. RT toxicity and clinician-rated cosmesis were compared between cases and controls. Overall survival, disease-free survival, and local recurrence-free survival were estimated using the Kaplan-Meier method. RESULTS The median follow-up was 49.9 months for cases and 53.0 months for controls, and 67% of cases and controls were treated with hypofractionated RT. There was no difference in grade 2/3 acute toxicity between cases and controls (26.4% vs. 16.5%, respectively; P = .148). There was a significantly higher rate of grade 2/3 late toxicity among cases (25.8% vs 12.1% among controls; P = .049). Active AD at the time of RT increased the rate of grade 2/3 late toxicity compared with controls (41.7% in cases vs. 11.4% in controls; P = .018). Among patients treated with hypofractionated RT, there was no difference in acute or late grade 2/3 toxicity between cases and controls (acute: 13.1% in cases vs. 11.5% in controls [P > 0.9]; late: 11.9% in cases vs. 13.1% in controls [P > 0.9]). The rates of good/excellent clinician-rated cosmesis were similar between groups (92.9% in cases vs. 98.9% in controls; P = .142). CONCLUSIONS In the largest matched case-control study of patients with CTD treated with conventional and hypofractionated RT, we demonstrate low rates of radiation toxicity, with good to excellent clinician-rated cosmesis. There was increased late toxicity in cases, especially in patients with active AD at time of RT. There was no increase in acute or late toxicity in the patients treated with hypofractionation.
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