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Bonaparte I, Fragnoli F, Gregucci F, Carbonara R, Di Guglielmo FC, Surgo A, Davì V, Caliandro M, Sanfrancesco G, De Pascali C, Aga A, Indellicati C, Parabita R, Cuscito R, Cardetta P, Laricchia M, Antonicelli M, Ciocia A, Curci D, Guida P, Ciliberti MP, Fiorentino A. Improving Quality Assurance in a Radiation Oncology Using ARIA Visual Care Path. J Pers Med 2024; 14:416. [PMID: 38673043 PMCID: PMC11051245 DOI: 10.3390/jpm14040416] [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: 03/04/2024] [Revised: 04/07/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
PURPOSE Errors and incidents may occur at any point within radiotherapy (RT). The aim of the present retrospective analysis is to evaluate the impact of a customized ARIA Visual Care Path (VCP) on quality assurance (QA) for the RT process. MATERIALS AND METHODS The ARIA VCP was implemented in June 2019. The following tasks were customized and independently verified (by independent checks from radiation oncologists, medical physics, and radiation therapists): simulation, treatment planning, treatment start verification, and treatment completion. A retrospective analysis of 105 random and unselected patients was performed, and 945 tasks were reviewed. Patients' reports were categorized based on treatment years period: 2019-2020 (A); 2021 (B); and 2022-2023 (C). The QA metrics included data for timeliness of task completion and data for minor and major incidents. The major incidents were defined as incorrect prescriptions of RT dose, the use of different immobilization systems during RT compared to the simulation, the absence of surface-guided RT data for patients' positioning, incorrect dosimetric QA for treatment plans, and failure to complete RT as originally planned. A sample size of approximately 100 was able to obtain an upper limit of 95% confidence interval below 5-10% in the case of zero or one major incident. RESULTS From June 2019 to December 2023, 5300 patients were treated in our RT department, an average of 1300 patients per year. For the purpose of this analysis, one hundred and five patients were chosen for the study and were subsequently evaluated. All RT staff achieved a 100% compliance rate in the ARIA VCP timely completion. A total of 36 patients were treated in Period A, 34 in Period B, and 35 in Period C. No major incidents were identified, demonstrating a major incident rate of 0.0% (95% CI 0.0-3.5%). A total of 26 out of 945 analyzed tasks (3.8%) were reported as minor incidents: absence of positioning photo in 32 cases, lack of patients' photo, and absence of plan documents in 4 cases. When comparing periods, incidents were statistically less frequent in Period C. CONCLUSIONS Although the present analysis has some limitations, its outcomes demonstrated that software for the RT workflow, which is fully integrated with both the record-and-verify and treatment planning systems, can effectively manage the patient's care path. Implementing the ARIA VCP improved the efficiency of the RT care path workflow, reducing the risk of major and minor incidents.
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Affiliation(s)
- Ilaria Bonaparte
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Federica Fragnoli
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Fabiana Gregucci
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Roberta Carbonara
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Fiorella Cristina Di Guglielmo
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Alessia Surgo
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Valerio Davì
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Morena Caliandro
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Giuseppe Sanfrancesco
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Christian De Pascali
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Alberto Aga
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Chiara Indellicati
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Rosalinda Parabita
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Rosilda Cuscito
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Pietro Cardetta
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Maurizio Laricchia
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Michele Antonicelli
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Annarita Ciocia
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Domenico Curci
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Pietro Guida
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Maria Paola Ciliberti
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Alba Fiorentino
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
- Department of Medicine and Surgery, LUM University, 70010 Bari, Italy
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Abouegylah M, Elemary O, Ahmed AA, ElFeky AM, Fayed H, Gawish M, Mahmoud AA, Gawish A. Impact of breath hold on regional nodal irradiation and heart volume in field in left breast cancer adjuvant irradiation. Clin Transl Oncol 2024; 26:288-296. [PMID: 37382756 DOI: 10.1007/s12094-023-03256-9] [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: 02/17/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE Compared to the free-breathing technique, adjuvant left breast irradiation after breast-conserving surgery or mastectomy using the breath-hold method significantly reduces the heart mean dose, Left anterior descending artery, and ipsilateral lung doses. Movement with deep inspiration may also reduce heart volume in the field and regional node doses. MATERIALS AND METHODS Pre-radiotherapy planning CT was performed in the free-breathing, and breath-hold techniques using RPM, demographic information, clinicopathological data, heart volume in the field, heart mean dose, LAD mean dose, and regional nodal doses were calculated in both free breathing and DIBH. Fifty patients with left breast cancer receiving left breast adjuvant radiation were enrolled. RESULTS There was no significant difference in axillary LN coverage between the two techniques, except for SCL maximum dose, Axilla I node maximum dose, and Axilla II minimum dose in favor of the breath hold technique. The mean age was 47.54 years, 78% had GII IDC, 66% had positive LVSI results, and 74% of patients had T2. The breath hold strategy resulted in considerably decreased mean heart dose (p = 0.000), LAD dose (p = 0.000), ipsilateral lung mean dose (p = 0.012), and heart volume if the field (p = 0.013). The mean cardiac dosage and the dose of the LAD were significantly correlated (p = 0.000, R = 0.673). Heart volume in the field and heart mean dosage was not significantly correlated (p = 0.285, r = - 0.108). CONCLUSION When compared to free breathing scans, DIBH procedures result in considerably reduced dosage to the OAR and no appreciable changes in dose exposure to regional lymph node stations in patients with left-sided breast cancer.
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Affiliation(s)
- Mohamed Abouegylah
- Department of Clinical Oncology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - O Elemary
- Department of Clinical Oncology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Amany Mostafa ElFeky
- Department of Clinical Oncology, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Haytham Fayed
- Department of General Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mostafa Gawish
- Department of General Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Amr A Mahmoud
- Department of Clinical Oncology, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Ahmed Gawish
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
- Department of Radiation Oncology, Marburg Ion-Beam Therapy Center (MIT), Heidelberg University Hospital, Marburg, Germany.
- Department of Radiation Oncology, Marburg University Hospital, Marburg, Germany.
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3
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Li G. Advances and potential of optical surface imaging in radiotherapy. Phys Med Biol 2022; 67:10.1088/1361-6560/ac838f. [PMID: 35868290 PMCID: PMC10958463 DOI: 10.1088/1361-6560/ac838f] [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: 12/08/2021] [Accepted: 07/22/2022] [Indexed: 11/12/2022]
Abstract
This article reviews the recent advancements and future potential of optical surface imaging (OSI) in clinical applications as a four-dimensional (4D) imaging modality for surface-guided radiotherapy (SGRT), including OSI systems, clinical SGRT applications, and OSI-based clinical research. The OSI is a non-ionizing radiation imaging modality, offering real-time 3D surface imaging with a large field of view (FOV), suitable for in-room interactive patient setup, and real-time motion monitoring at any couch rotation during radiotherapy. So far, most clinical SGRT applications have focused on treating superficial breast cancer or deep-seated brain cancer in rigid anatomy, because the skin surface can serve as tumor surrogates in these two clinical scenarios, and the procedures for breast treatments in free-breathing (FB) or at deep-inspiration breath-hold (DIBH), and for cranial stereotactic radiosurgery (SRS) and radiotherapy (SRT) are well developed. When using the skin surface as a body-position surrogate, SGRT promises to replace the traditional tattoo/laser-based setup. However, this requires new SGRT procedures for all anatomical sites and new workflows from treatment simulation to delivery. SGRT studies in other anatomical sites have shown slightly higher accuracy and better performance than a tattoo/laser-based setup. In addition, radiographical image-guided radiotherapy (IGRT) is still necessary, especially for stereotactic body radiotherapy (SBRT). To go beyond the external body surface and infer an internal tumor motion, recent studies have shown the clinical potential of OSI-based spirometry to measure dynamic tidal volume as a tumor motion surrogate, and Cherenkov surface imaging to guide and assess treatment delivery. As OSI provides complete datasets of body position, deformation, and motion, it offers an opportunity to replace fiducial-based optical tracking systems. After all, SGRT has great potential for further clinical applications. In this review, OSI technology, applications, and potential are discussed since its first introduction to radiotherapy in 2005, including technical characterization, different commercial systems, and major clinical applications, including conventional SGRT on top of tattoo/laser-based alignment and new SGRT techniques attempting to replace tattoo/laser-based setup. The clinical research for OSI-based tumor tracking is reviewed, including OSI-based spirometry and OSI-guided tumor tracking models. Ongoing clinical research has created more SGRT opportunities for clinical applications beyond the current scope.
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Affiliation(s)
- Guang Li
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, United States of America
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Groot Koerkamp ML, van den Bongard HD, Philippens ME, van der Leij F, Mandija S, Houweling AC. Intrafraction motion during radiotherapy of breast tumor, breast tumor bed, and individual axillary lymph nodes on cine magnetic resonance imaging. Phys Imaging Radiat Oncol 2022; 23:74-79. [PMID: 35833200 PMCID: PMC9271760 DOI: 10.1016/j.phro.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 11/17/2022] Open
Abstract
Intrafraction motion of the breast and individual axillary lymph nodes was studied. Displacements were investigated using cine magnetic resonance imaging. Motion was separated into breathing and drift components. Medians of the maximum displacements were small, <3 mm for breast and lymph nodes. Intrafraction motion of the tumor (bed) was less in prone than in supine position.
Background and purpose In (ultra-)hypofractionation, the contribution of intrafraction motion to treatment accuracy becomes increasingly important. Our purpose was to evaluate intrafraction motion and resulting geometric uncertainties for breast tumor (bed) and individual axillary lymph nodes, and to compare prone and supine position for the breast tumor (bed). Materials and methods During 1–3 min of free breathing, we acquired transverse/sagittal interleaved 1.5 T cine magnetic resonance imaging (MRI) of the breast tumor (bed) in prone and supine position and coronal/sagittal cine MRI of individual axillary lymph nodes in supine position. A total of 31 prone and 23 supine breast cine MRI (in 23 women) and 52 lymph node cine MRI (in 24 women) were included. Maximum displacement, breathing amplitude, and drift were analyzed using deformable image registration. Geometric uncertainties were calculated for all displacements and for breathing motion only. Results Median maximum displacements (range over the three orthogonal orientations) were 1.1–1.5 mm for the breast tumor (bed) in prone and 1.8–3.0 mm in supine position, and 2.2–2.4 mm for lymph nodes. Maximum displacements were significantly smaller in prone than in supine position, mainly due to smaller breathing amplitude: 0.6–0.9 mm in prone vs. 0.9–1.4 mm in supine. Systematic and random uncertainties were 0.1–0.4 mm in prone position and 0.2–0.8 mm in supine position for the tumor (bed), and 0.4–0.6 mm for the lymph nodes. Conclusion Intrafraction motion of breast tumor (bed) and individual lymph nodes was small. Motion of the tumor (bed) was smaller in prone than in supine position.
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Affiliation(s)
- Maureen L Groot Koerkamp
- Department of Radiotherapy, UMC Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
- Corresponding author.
| | | | | | - Femke van der Leij
- Department of Radiotherapy, UMC Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Stefano Mandija
- Department of Radiotherapy, UMC Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
- Computational Imaging Group for MR Diagnostics & Therapy, Center for Image Sciences, UMC Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Antonetta C Houweling
- Department of Radiotherapy, UMC Utrecht, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
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Wolf J, Kurz S, Rothe T, Serpa M, Scholber J, Erbes T, Gkika E, Baltas D, Verma V, Krug D, Juhasz-Böss I, Grosu AL, Nicolay NH, Sprave T. Incidental irradiation of the regional lymph nodes during deep inspiration breath-hold radiation therapy in left-sided breast cancer patients: a dosimetric analysis. BMC Cancer 2022; 22:682. [PMID: 35729505 PMCID: PMC9210647 DOI: 10.1186/s12885-022-09784-x] [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: 04/21/2022] [Accepted: 06/01/2022] [Indexed: 12/01/2022] Open
Abstract
Background Radiotherapy using the deep inspiration breath-hold (DIBH) technique compared with free breathing (FB) can achieve substantial reduction of heart and lung doses in left-sided breast cancer cases. The anatomical organ movement in deep inspiration also cause unintended exposure of locoregional lymph nodes to the irradiation field. Methods From 2017–2020, 148 patients with left-sided breast cancer underwent breast conserving surgery (BCS) or mastectomy (ME) with axillary lymph node staging, followed by adjuvant irradiation in DIBH technique. Neoadjuvant or adjuvant systemic therapy was administered depending on hormone receptor and HER2-status. CT scans in FB and DIBH position with individual coaching and determination of the breathing amplitude during the radiation planning CT were performed for all patients. Intrafractional 3D position monitoring of the patient surface in deep inspiration and gating was performed using Sentinel and Catalyst HD 3D surface scanning systems (C-RAD, Catalyst, C-RAD AB, Uppsala, Sweden). Three-dimensional treatment planning was performed using standard tangential treatment portals (6 or 18 MV). The delineation of ipsilateral locoregional lymph nodes was done on the FB and the DIBH CT-scan according to the RTOG recommendations. Results The mean doses (Dmean) in axillary lymph node (AL) level I, II and III in DIBH were 32.28 Gy (range 2.87–51.7), 20.1 Gy (range 0.44–53.84) and 3.84 Gy (range 0.25–39.23) vs. 34.93 Gy (range 10.52–50.40), 16.40 Gy (range 0.38–52.40) and 3.06 Gy (range 0.21–40.48) in FB (p < 0.0001). Accordingly, in DIBH the Dmean for AL level I were reduced by 7.59%, whereas for AL level II and III increased by 22.56% and 25.49%, respectively. The Dmean for the supraclavicular lymph nodes (SC) in DIBH was 0.82 Gy (range 0.23–4.11), as compared to 0.84 Gy (range 0.22–10.80) with FB (p = 0.002). This results in a mean dose reduction of 2.38% in DIBH. The Dmean for internal mammary lymph nodes (IM) was 12.77 Gy (range 1.45–39.09) in DIBH vs. 11.17 Gy (range 1.34–44.24) in FB (p = 0.005). This yields a mean dose increase of 14.32% in DIBH. Conclusions The DIBH technique may result in changes in the incidental dose exposure of regional lymph node areas.
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Affiliation(s)
- Jule Wolf
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Steffen Kurz
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Thomas Rothe
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Marco Serpa
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Jutta Scholber
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Thalia Erbes
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Dimos Baltas
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Vivek Verma
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Molecular and Radiation Oncology, German Cancer Research Center (Dkfz), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany. .,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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Reproducibility of repeated breathhold and impact of breathhold failure in whole breast and regional nodal irradiation in prone crawl position. Sci Rep 2022; 12:1887. [PMID: 35115610 PMCID: PMC8814154 DOI: 10.1038/s41598-022-05957-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 01/20/2022] [Indexed: 11/09/2022] Open
Abstract
In whole breast and regional nodal irradiation (WB + RNI), breathhold increases organ at risk (OAR) sparing. WB + RNI is usually performed in supine position, because positioning materials obstruct beam paths in prone position. Recent advancements allow prone WB + RNI (pWB + RNI) with increased sparing of OARs compared to supine WB + RNI. We evaluate positional and dosimetrical impact of repeated breathhold (RBH) and failure to breathhold (FTBH) in pWB + RNI. Twenty left-sided breast cancer patients were scanned twice in breathhold (baseline and RBH) and once free breathing (i.e. FTBH). Positional impact was evaluated using overlap index (OI) and Dice similarity coefficient (DSC). Dosimetrical impact was assessed by beam transposition from the baseline plan. Mean OI and DSC ranges were 0.01–0.98 and 0.01–0.92 for FTBH, and 0.73–1 and 0.69–1 for RBH. Dosimetric impact of RBH was negligible. FTBH significantly decreased minimal dose to CTV WBI, level II and the internal mammary nodes, with adequate mean doses. FTBH significantly increased heart, LAD, left lung and esophagus dose. OI and DSC for RBH and FTBH show reproducible large ROI positions. Small ROIs show poor overlap. FTBH maintained adequate target coverage but increased heart, LAD, ipsilateral lung and esophagus dose. RBH is a robust technique in pWB + RNI. (Clinicaltrials.gov: NCT05179161, registered 05/01/2022).
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7
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Chen M, Zang S, Yu H, Ning L, Huang H, Bu L, Ge J, Xu M, Tang Q, Zhao F, Yao G, Yan S. Immobilization-assisted abdominal deep inspiration breath-hold in post-mastectomy radiotherapy of left-sided breast cancer with internal mammary chain coverage. Quant Imaging Med Surg 2021; 11:3314-3326. [PMID: 34249656 DOI: 10.21037/qims-20-831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/18/2020] [Indexed: 12/24/2022]
Abstract
Background Whether to prophylactically irradiate the ipsilateral internal mammary chain (IMC) in post-mastectomy radiotherapy (PMRT) remains controversial because of equivocal clinical benefits against the added toxicities. Our previous study revealed that the cardiac dose was decreased during left-sided breast radiotherapy with abdominal deep inspiration breath-hold (aDIBH) as compared with free-breathing (FB) and thoracic deep inspiration breath-hold (tDIBH). Here we present the dosimetric advantage of aDIBH for patients undergoing PMRT with IMC coverage. Methods We prospectively analyzed 19 patients with left-sided breast cancer who underwent PMRT. Patients underwent computed tomography (CT) simulation under both free-breathing (FB) and aDIBH. The heart, left anterior descending coronary artery (LAD), lungs, and the contralateral breast was defined as organs at risk (OARs). Three-dimensional conformal radiation therapy (3D-CRT), inverse planning intensity-modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT) were used to calculate the doses received by both the planning target volume (PTV) and OARs, which were compared using the Wilcoxon signed-rank test. Results Compared with FB, the Dmean of the heart and LAD were respectively reduced by 3.5 Gy (P<0.003) and 8.9 Gy (P<0.001) in 3D-CRT, 2.6 Gy (P<0.001), and 7.8 Gy (P=0.001) in IMRT, 1.5 Gy (P<0.001) and 4.5 Gy (P=0.001) in VMAT plans under aDIBH. Among all these plans, the Dmean of the heart was lowest in aDIBH IMRT and 1.3 Gy lower than in aDIBH VMAT (P=0.002). aDIBH IMRT also resulted in a significantly reduced dose to the ipsilateral lung than plans under FB (P<0.05). Dmean and V5 to the contralateral lung and breast were higher in VMAT plans (P<0.05). Conclusions Using an immobilization-assisted aDIBH technique, radiation doses to the heart can be kept at reasonably low levels even if IMC is included in the clinical target volume (CTV). Among 3D-CRT, IMRT, and VMAT plans, IMRT plus aDIBH results in the best heart-sparing effect. We recommend that the aDIBH technique be routinely applied in suitable patients if the IMC is irradiated.
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Affiliation(s)
- Meiqin Chen
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou and Department of Radiation Oncology, Affiliated Jinhua Hospital, College of Medicine, Zhejiang University, Jinhua, China
| | - Shoumei Zang
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Hao Yu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Lihua Ning
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Huijie Huang
- Department of Radiation Oncology, YiLi Friendship Hospital, Yili, China
| | - Luyi Bu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jia Ge
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Mengyou Xu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Qiuying Tang
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Feng Zhao
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Guorong Yao
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Senxiang Yan
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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8
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Gaál S, Kahán Z, Paczona V, Kószó R, Drencsényi R, Szabó J, Rónai R, Antal T, Deák B, Varga Z. Deep-inspirational breath-hold (DIBH) technique in left-sided breast cancer: various aspects of clinical utility. Radiat Oncol 2021; 16:89. [PMID: 33985547 PMCID: PMC8117634 DOI: 10.1186/s13014-021-01816-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background Studying the clinical utility of deep-inspirational breath-hold (DIBH) in left breast cancer radiotherapy (RT) was aimed at focusing on dosimetry and feasibility aspects. Methods In this prospective trial all enrolled patients went through planning CT in supine position under both DIBH and free breathing (FB); in whole breast irradiation (WBI) cases prone CT was also taken. In 3-dimensional conformal radiotherapy (3DCRT) plans heart, left anterior descending coronary artery (LAD), ipsilateral lung and contralateral breast doses were analyzed. The acceptance of DIBH technique as reported by the patients and the staff was analyzed; post-RT side-effects including radiation lung changes (visual scores and lung density measurements) were collected. Results Among 130 enrolled patients 26 were not suitable for the technique while in 16, heart or LAD dose constraints were not met in the DIBH plans. Among 54 and 34 patients receiving WBI and postmastectomy/nodal RT, respectively with DIBH, mean heart dose (MHD) was reduced to < 50%, the heart V25 Gy to < 20%, the LAD mean dose to < 40% and the LAD maximum dose to about 50% as compared to that under FB; the magnitude of benefit was related to the relative increase of the ipsilateral lung volume at DIBH. Nevertheless, heart and LAD dose differences (DIBH vs. FB) individually varied. Among the WBI cases at least one heart/LAD dose parameter was more favorable in the prone or in the supine FB plan in 15 and 4 cases, respectively; differences were numerically small. All DIBH patients completed the RT, inter-fraction repositioning accuracy and radiation side-effects were similar to that of other breast RT techniques. Both the patients and radiographers were satisfied with the technique. Conclusions DIBH is an excellent heart sparing technique in breast RT, but about one-third of the patients do not benefit from that otherwise laborious procedure or benefit less than from an alternative method. Trial registration: retrospectively registered under ISRCTN14360721 (February 12, 2021) Supplementary information The online version contains supplementary material available at 10.1186/s13014-021-01816-3.
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Affiliation(s)
- Szilvia Gaál
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Zsuzsanna Kahán
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Viktor Paczona
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Renáta Kószó
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Rita Drencsényi
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Judit Szabó
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Ramóna Rónai
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Tímea Antal
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Bence Deák
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary
| | - Zoltán Varga
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, 6720, Szeged, Hungary.
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9
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Krug D, Vonthein R, Schreiber A, Boicev AD, Zimmer J, Laubach R, Weidner N, Dinges S, Hipp M, Schneider R, Weinstrauch E, Martin T, Hörner-Rieber J, Olbrich D, Illen A, Heßler N, König IR, Dellas K, Dunst J. Impact of guideline changes on adoption of hypofractionation and breast cancer patient characteristics in the randomized controlled HYPOSIB trial. Strahlenther Onkol 2020; 197:802-811. [PMID: 33320286 PMCID: PMC8397631 DOI: 10.1007/s00066-020-01730-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022]
Abstract
Purpose Hypofractionated radiotherapy is the standard of care for adjuvant whole breast radiotherapy (RT). However, adoption has been slow. The indication for regional nodal irradiation has been expanded to include patients with 0–3 involved lymph nodes. We investigated the impact of the publication of the updated German S3 guidelines in 2017 on adoption of hypofractionation and enrollment of patients with lymph node involvement within a randomized controlled phase III trial. Methods In the experimental arm of the HYPOSIB trial (NCT02474641), hypofractionated RT with simultaneous integrated boost (SIB) was used. In the standard arm, RT could be given as hypofractionated RT with sequential boost (HFseq), normofractionated RT with sequential boost (NFseq), or normofractionated RT with SIB (NFSIB). The cutoff date for the updated German S3 guidelines was December 17, 2017. Temporal trends were analyzed by generalized linear regression models. Multiple logistic regression models were used to investigate the influence of time (prior to/after guideline) and setting (university hospital/other institutions) on the fractionation patterns. Results Enrollment of patients with involved lymph nodes was low throughout the trial. Adoption of HFseq increased over time and when using the guideline publication date as cutoff. Results of the multiple logistic regressions showed an interaction between time and setting. Furthermore, the use of HFseq was significantly more common in university hospitals. Conclusion The use of HFseq in the standard arm increased over the course of the HYPOSIB trial and after publication of the S3 guideline update. This was primarily driven by patients treated in university hospitals. Enrolment of patients with lymph node involvement was low throughout the trial.
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Affiliation(s)
- David Krug
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Andreas Schreiber
- Praxis für Strahlentherapie Dr. med. Andreas Schreiber, Dresden, Germany
| | - Alexander D Boicev
- Klinik für Strahlentherapie und Radioonkologie, Heinrich-Braun-Klinikum Zwickau, Zwickau, Germany
| | - Jörg Zimmer
- Praxis für Strahlentherapie Dr. med. Andreas Schreiber, Dresden, Germany
| | - Reinhold Laubach
- Klinik für Radio-Onkologie, St. Marien-Krankenhaus Siegen, Siegen, Germany
| | - Nicola Weidner
- Klinik für Strahlentherapie, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Stefan Dinges
- Klinik für Strahlentherapie & Radioonkologie, Klinikum Lüneburg, Lüneburg, Germany
| | - Matthias Hipp
- Klinik für Strahlentherapie, Klinikum Amberg, Amberg, Germany
| | - Ralf Schneider
- Klinik für Strahlentherapie, Helios-Kliniken Schwerin, Schwerin, Germany
| | - Evelyn Weinstrauch
- Praxis für Radioonkologie, Johanniter-Zentren für Medizinische Versorgung Stendal, Stendal, Germany
| | - Thomas Martin
- Medizinisches Versorgungszentrum Fachbereich RadioOnkologie, Klinikum Bremen-Mitte, Bremen, Germany
| | - Juliane Hörner-Rieber
- RadioOnkologie und Strahlentherapie, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Denise Olbrich
- ZKS Lübeck (Zentrum für klinische Studien Lübeck), Universität zu Lübeck, Lübeck, Germany
| | - Alicia Illen
- ZKS Lübeck (Zentrum für klinische Studien Lübeck), Universität zu Lübeck, Lübeck, Germany
| | - Nicole Heßler
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Inke R König
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Kathrin Dellas
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
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10
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Freislederer P, Kügele M, Öllers M, Swinnen A, Sauer TO, Bert C, Giantsoudi D, Corradini S, Batista V. Recent advanced in Surface Guided Radiation Therapy. Radiat Oncol 2020; 15:187. [PMID: 32736570 PMCID: PMC7393906 DOI: 10.1186/s13014-020-01629-w] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/21/2020] [Indexed: 01/27/2023] Open
Abstract
The growing acceptance and recognition of Surface Guided Radiation Therapy (SGRT) as a promising imaging technique has supported its recent spread in a large number of radiation oncology facilities. Although this technology is not new, many aspects of it have only recently been exploited. This review focuses on the latest SGRT developments, both in the field of general clinical applications and special techniques.SGRT has a wide range of applications, including patient positioning with real-time feedback, patient monitoring throughout the treatment fraction, and motion management (as beam-gating in free-breathing or deep-inspiration breath-hold). Special radiotherapy modalities such as accelerated partial breast irradiation, particle radiotherapy, and pediatrics are the most recent SGRT developments.The fact that SGRT is nowadays used at various body sites has resulted in the need to adapt SGRT workflows to each body site. Current SGRT applications range from traditional breast irradiation, to thoracic, abdominal, or pelvic tumor sites, and include intracranial localizations.Following the latest SGRT applications and their specifications/requirements, a stricter quality assurance program needs to be ensured. Recent publications highlight the need to adapt quality assurance to the radiotherapy equipment type, SGRT technology, anatomic treatment sites, and clinical workflows, which results in a complex and extensive set of tests.Moreover, this review gives an outlook on the leading research trends. In particular, the potential to use deformable surfaces as motion surrogates, to use SGRT to detect anatomical variations along the treatment course, and to help in the establishment of personalized patient treatment (optimized margins and motion management strategies) are increasingly important research topics. SGRT is also emerging in the field of patient safety and integrates measures to reduce common radiotherapeutic risk events (e.g. facial and treatment accessories recognition).This review covers the latest clinical practices of SGRT and provides an outlook on potential applications of this imaging technique. It is intended to provide guidance for new users during the implementation, while triggering experienced users to further explore SGRT applications.
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Affiliation(s)
- P. Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - M. Kügele
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
- Medical Radiation Physics, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - M. Öllers
- Maastricht Radiation Oncology (MAASTRO), Maastricht, the Netherlands
| | - A. Swinnen
- Maastricht Radiation Oncology (MAASTRO), Maastricht, the Netherlands
| | - T.-O. Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - C. Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - D. Giantsoudi
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, USA
| | - S. Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - V. Batista
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
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11
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Reitz D, Walter F, Schönecker S, Freislederer P, Pazos M, Niyazi M, Landry G, Alongi F, Bölke E, Matuschek C, Reiner M, Belka C, Corradini S. Stability and reproducibility of 6013 deep inspiration breath-holds in left-sided breast cancer. Radiat Oncol 2020; 15:121. [PMID: 32448224 PMCID: PMC7247126 DOI: 10.1186/s13014-020-01572-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/17/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Patients with left-sided breast cancer frequently receive deep inspiration breath-hold (DIBH) radiotherapy to reduce the risk of cardiac side effects. The aim of the present study was to analyze intra-breath-hold stability and inter-fraction breath-hold reproducibility in clinical practice. Material and methods Overall, we analyzed 103 patients receiving left-sided breast cancer radiotherapy using a surface-guided DIBH technique. During each treatment session the vertical motion of the patient was continuously measured by a surface guided radiation therapy (SGRT) system and automated gating control (beam on/off) was performed using an audio-visual patient feedback system. Dose delivery was automatically triggered when the tracking point was within a predefined gating window. Intra-breath-hold stability and inter-fraction reproducibility across all fractions of the entire treatment course were analyzed per patient. Results In the present series, 6013 breath-holds during beam-on time were analyzed. The mean amplitude of the gating window from the baseline breathing curve (maximum expiration during free breathing) was 15.8 mm (95%-confidence interval: [8.5–30.6] mm) and had a width of 3.5 mm (95%-CI: [2–4.3] mm). As a measure of intra-breath-hold stability, the median standard deviation of the breath-hold level during DIBH was 0.3 mm (95%-CI: [0.1–0.9] mm). Similarly, the median absolute intra-breath-hold linear amplitude deviation was 0.4 mm (95%-CI: [0.01–2.1] mm). Reproducibility testing showed good inter-fractional reliability, as the maximum difference in the breathing amplitudes in all patients and all fractions were 1.3 mm on average (95%-CI: [0.5–2.6] mm). Conclusion The clinical integration of an optical surface scanner enables a stable and reliable DIBH treatment delivery during SGRT for left-sided breast cancer in clinical routine.
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Affiliation(s)
- D Reitz
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - F Walter
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - S Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - P Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - M Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - M Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - G Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - F Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar-Verona, Italy.,University of Brescia, Brescia, Italy
| | - E Bölke
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - C Matuschek
- Department of Radiation Oncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - M Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - C Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - S Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
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12
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Duma MN. An Update on Regional Nodal Irradiation: Indication, Target Volume Delineation, and Radiotherapy Techniques. Breast Care (Basel) 2020; 15:128-135. [PMID: 32398981 DOI: 10.1159/000507040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/09/2020] [Indexed: 12/15/2022] Open
Abstract
Background Tremendous changes have occurred in the treatment of breast cancer. This paper reviews and unifies the available data on modern axillary management of breast cancer patients with focus on the target volume delineation for regional nodal irradiation according to the most important contouring guidelines, the European Society for Radiotherapy and Oncology (ESTRO) and the Radiation Therapy and Oncology Group (RTOG). Summary The use of extensive radiotherapy target volumes (level I, II, III, IV) is probably not necessary for all patients to reproduce the clinical benefit shown in the available randomized trials (EORTC, MA.20, AMAROS, Z0011). Nevertheless, given the results in the MA.20 trial, where the patients received more modern systemic therapies and high irradiation doses in the medial paraclavicular region (level IV) and level II, it can be justified to include these regions completely in selected high-risk patients. Key Messages High-tangent irradiation results in a similar dose distribution in axillary levels I and II compared to the AMAROS treatment field design in some patients. This supports earlier assumptions that irradiation may have accounted for the good results after sentinel lymph node dissection alone in the Z0011 trial. The ESTRO and RTOG clinical target volume (CTV) definitions cover sufficiently the metastatic lymph node hotspots, with a better coverage for the ESTRO CTV. Further, contouring according to the ESTRO would spare a significantly larger part of the healthy lymphatic system, making it our preferred contouring atlas. Modern radiotherapy techniques, such as deep inspiration breath hold, should be cautiously employed in patients treated according to the inclusion criteria of the Z0011 as it will result in a lower dose to the axillary levels.
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Affiliation(s)
- Marciana Nona Duma
- Department of Radiotherapy and Radiation Oncology, University Hospital of the Friedrich Schiller University, Jena, Germany
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13
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Haussmann J, Corradini S, Nestle-Kraemling C, Bölke E, Njanang FJD, Tamaskovics B, Orth K, Ruckhaeberle E, Fehm T, Mohrmann S, Simiantonakis I, Budach W, Matuschek C. Recent advances in radiotherapy of breast cancer. Radiat Oncol 2020; 15:71. [PMID: 32228654 PMCID: PMC7106718 DOI: 10.1186/s13014-020-01501-x] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/18/2020] [Indexed: 01/08/2023] Open
Abstract
Radiation therapy is an integral part of the multidisciplinary management of breast cancer. Regional lymph node irradiation in younger trials seems to provide superior target coverage as well as a reduction in long-term toxicity resulting in a small benefit in the overall survival rate. For partial breast irradiation there are now two large trials available which support the role of partial breast irradiation in low risk breast cancer patients. Multiple randomized trials have established that a sequentially applied dose to the tumor bed improves local control with the cost of worse cosmetic results.
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Affiliation(s)
- Jan Haussmann
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Carolin Nestle-Kraemling
- Department of Gynecologic and Obstetrics, Evanglisches Krankenhaus Dusseldorf, Dusseldorf, Germany
| | - Edwin Bölke
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany.
| | | | - Bálint Tamaskovics
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Klaus Orth
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Eugen Ruckhaeberle
- Department of Gynecology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Tanja Fehm
- Department of Gynecology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Svjetlana Mohrmann
- Department of Gynecology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Ioannis Simiantonakis
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Wilfried Budach
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Christiane Matuschek
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
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14
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Cao N, Kalet AM, Young LA, Fang LC, Kim JN, Mayr NA, Meyer J. Predictors of cardiac and lung dose sparing in DIBH for left breast treatment. Phys Med 2019; 67:27-33. [PMID: 31629280 DOI: 10.1016/j.ejmp.2019.09.240] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 09/10/2019] [Accepted: 09/25/2019] [Indexed: 01/23/2023] Open
Abstract
This retrospective study of left breast radiation therapy (RT) investigates the correlation between anatomical parameters and dose to heart or/and left lung in deep inspiration breath-hold (DIBH) compared to free-breathing (FB) technique. Anatomical parameters of sixty-seven patients, treated with a step-and-shoot technique to 50 Gy or 50.4 Gy were included. They consisted of the cardiac contact distances in axial (CCDax) and parasagittal (CCDps) planes, and the lateral heart-to-chest distance (HCD). Correlation analysis was performed to identify predictors for heart and lung dose sparing. Paired t-test and linear regression were used for data analysis with significance level of p = 0.05. All dose metrics for heart and lung were significantly reduced with DIBH, however 21% of patients analyzed had less than 1.0 Gy mean heart dose reduction. Both FB-CCDpsdistance and FB-HCD correlated with FB mean heart dose and mean DIBH heart dose reduction. The strongest correlation was observed for the ratio of FB-CCDpsand FB-HCD with heart dose sparing. A FB-CCDps and FB-HCD model was developed to predict DIBH induced mean heart dose reduction, with 1.04 Gy per unit of FB-CCDps/FB-HCD. Variation between predicted and actual mean heart dose reduction ranged from -0.6 Gy to 0.6 Gy. In this study, FB-CCDps and FB-HCD distance served as predictors for heart dose reduction with DIBH equally, with FB-CCDps/FB-HCD as a stronger predictor. These parameters and the prediction model could be further investigated for use as a tool to better select patients who will benefit from DIBH.
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Affiliation(s)
- Ning Cao
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA.
| | - Alan M Kalet
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Lori A Young
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - L Christine Fang
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Janice N Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Juergen Meyer
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
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15
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Karpf D, Sakka M, Metzger M, Grabenbauer GG. Left breast irradiation with tangential intensity modulated radiotherapy (t-IMRT) versus tangential volumetric modulated arc therapy (t-VMAT): trade-offs between secondary cancer induction risk and optimal target coverage. Radiat Oncol 2019; 14:156. [PMID: 31477165 PMCID: PMC6721379 DOI: 10.1186/s13014-019-1363-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 08/21/2019] [Indexed: 02/06/2023] Open
Abstract
Background Adjuvant radiotherapy is the standard treatment after breast-conserving surgery. According to meta-analyses, adjuvant 3d-conventional irradiation reduces the risk of local recurrence and thereby improves long-term survival by 5–10%. However, there is an unintended exposure of organs such as the heart, lungs and contralateral breast. Irradiation of the left breast has been related to long-term effects like increased rates of coronary events as well as second cancer induction. Modern radiotherapy techniques such as tangential intensity modulated radiotherapy (t-IMRT) and tangential volumetric modulated arc therapy (t-VMAT) and particularly deep inspiration breath hold (DIBH) technique have been developed in order to improve coverage of target volume and to reduce dose to normal tissue. The aim of this study was to compare t-IMRT-plans with t-VMAT-plans in DIBH position for left-sided breast irradiation in terms of normal tissue exposure, i.e. of lungs, heart, left anterior descending coronary artery (LADCA), as well as homogeneity (HI) and conformity index (CI) and excess absolute risk (EAR) for second cancer induction for organs at risk (OAR) after irradiation. Methods Twenty patients, diagnosed with left-sided breast cancer and treated with breast-preserving surgery, were included in this planning study. For each patient DIBH-t-IMRT plan using 5 to 7 beams and t-VMAT plan using four rotations were generated to achieve 95% dose coverage to 95% of the volume. Data were evaluated on the basis of dose-volume histograms: Cardiac dose and LADCA (mean and maximum dose, D25% and D45%), dose to ipsilateral and contralateral lung (mean, D20%, D30%), dose to contralateral breast (mean dose), total monitor units, V5% of total body and normal tissue integral dose (NTID). In addition, homogeneity index and conformity index, as well as the excess absolute risk (EAR) to estimate the risk of second malignancy were calculated. Results T-IMRT showed a significant reduction in mean cardiac dose of 26% (p = 0.002) compared to t-VMAT, as well as a significant reduction in the mean dose to LADCA of 20% (p = 0.03). Following t-IMRT, mean dose to the left lung was increased by 5% (p = 0.006), whereas no significant difference was found in the mean dose to the right lung and contralateral breast between the two procedures. Monitor units were 31% (p = 0.000004) lower for t-IMRT than for t-VMAT. T-IMRT technique significantly reduced normal tissue integral dose (NTID) by 19% (p = 0.000005) and the V5% of total body by 24% (p = 0.0007). In contrast, t-VMAT improved CI and HI by 2% (p = 0.001) and 0.4% (p = 0.00001), respectively. EAR with t-IMRT was significantly lower, especially for contralateral lung and contralateral breast (2–5/10,000 person years) but not for ipsilateral lung. Conclusion Compared to t-VMAT, t-IMRT in left-sided breast irradiation significantly reduced dose to organs at risk as well as normal tissue integral dose, and V5% total body. EAR with t-IMRT was significantly lower for contralateral lung and contralateral breast. T-VMAT, however, achieved better homogeneity and conformity. This may be relevant in individual cases where sufficient coverage of medial lymphatic target volumes is warranted.
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Affiliation(s)
- Daniel Karpf
- Department of Radiation Oncology, Coburg Cancer Center, Coburg, Germany.,Medical Faculty of the Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany
| | - Mazen Sakka
- Department of Radiation Oncology, Coburg Cancer Center, Coburg, Germany
| | - Martin Metzger
- Division of Radiation Physics, Department of Radiation Oncology, Coburg Cancer Center, Coburg, Germany
| | - Gerhard G Grabenbauer
- Department of Radiation Oncology, Coburg Cancer Center, Coburg, Germany. .,Medical Faculty of the Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany.
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16
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Pazos M, Walter F, Reitz D, Schönecker S, Konnerth D, Schäfer A, Rottler M, Alongi F, Freislederer P, Niyazi M, Belka C, Corradini S. Impact of surface-guided positioning on the use of portal imaging and initial set-up duration in breast cancer patients. Strahlenther Onkol 2019; 195:964-971. [PMID: 31332457 DOI: 10.1007/s00066-019-01494-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/27/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The impact of optical surface guidance on the use of portal imaging and the initial set-up duration in patients receiving postoperative radiotherapy of the breast or chest wall was investigated. MATERIAL AND METHODS A retrospective analysis was performed including breast cancer patients who received postoperative radiotherapy between January 2016 and December 2016. One group of patients received treatment before the optical surface scanner was installed (no-OSS) and the other group was positioned using the additional information derived by the optical surface scanner (OSS). The duration of the initial set-up was recorded for each patient and a comparison of both groups was performed. Accordingly, the differences between planned and actually acquired portal images during the course of radiotherapy were compared between both groups. RESULTS A total of 180 breast cancer patients were included (90 no-OSS, 90 OSS) in this analysis. Of these, 30 patients with left-sided breast cancer received radiotherapy in deep inspiration breath hold (DIBH). The mean set-up time was 10 min and 18 s and no significant difference between the two groups of patients was found (p = 0.931). The mean set-up time in patients treated without DIBH was 9 min and 45 s compared to 13 min with DIBH (p < 0.001), as portal imaging was performed in DIBH. No significant difference was found in the number of acquired to the planned number of portal images during the entire radiotherapy treatment for both groups (p = 0.287). CONCLUSION Optical surface imaging is a valuable addition for primary patient set-up. The findings confirm that the addition of surface-based imaging did not prolong the clinical workflow and had no significant impact on the number of portal verification images carried out during the course of radiotherapy.
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Affiliation(s)
- Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.
| | - Daniel Reitz
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Dinah Konnerth
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Annemarie Schäfer
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maya Rottler
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Ospedale Sacro Cuore Don Calabria, Negrar-Verona, Italy.,University of Brescia, Brescia, Italy
| | - Philipp Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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17
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Haussmann J, Budach W, Tamaskovics B, Bölke E, Corradini S, Djiepmo-Njanang FJ, Kammers K, Matuschek C. Which target volume should be considered when irradiating the regional nodes in breast cancer? Results of a network-meta-analysis. Radiat Oncol 2019; 14:102. [PMID: 31186015 PMCID: PMC6558843 DOI: 10.1186/s13014-019-1280-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 04/22/2019] [Indexed: 01/11/2023] Open
Abstract
Purpose/objective(s) Radiation treatment to the regional nodes results in an improvement in survival in breast cancer according to a meta-analysis of randomized trials. However, different volumes were targeted in these studies: breast or chestwall only (WBI/CWI), inclusion of the medial supraclavicular region and axillary apex (MS + WBI/CWI) or additional inclusion of the internal mammary chain (IM + MS + WBI/CWI). The benefit of treating the medial supraclavicular region and axillary apex compared to tangential breast or chestwall irradiation only remains unclear. Materials/methods A literature search was conducted identifying trials for adjuvant radiation volumes in nodal irradiation after breast surgery and axillary treatment. Events and effect sizes were extracted from the publications for the endpoints of overall survival (OS), breast cancer-specific survival (BCSS), disease-free survival (DFS), distant metastasis-free survival (DMFS) and loco-regional control (LRC). A network meta-analysis was performed using MetaXL V5.3 with the inverse variance heterogeneity model. Results We found two randomized studies (n = 5836) comparing comprehensive nodal irradiation to sole breast treatment as well as one randomized (n = 1407) and one prospective cohort study (n = 3377) analysing the additional treatment of the internal mammary chain against sole local and supraclavicular and axillary apex radiation. Compared to WBI/CWI alone the treatment of IM + MS + WBI/CWI (HR = 0.88; CI:0.78-0.99; p = 0.036) results in improved OS unlike MS + WBI/CWI (HR = 0.99; CI:0.86-1.14; p = 0,89). These results are confirmed in BCSS: IM + MS + WBI/CWI (HR = 0.82; CI:0.72-0.92; p = 0.002) and MS + WBI/CWI (HR = 0.96; CI:0.79-1.18; p = 0.69). PFS is significantly improved with the treatment of MS + WBI/CWI (OR = 0.83; CI:0.71-0.97; p = 0.019). Both nodal treatment volumes improve LRC (MS + WBI/CWI OR = 0.74; CI:0.62-0.87; p = 0.004 and IM + MS + WBI/CWI OR = 0.60; CI:0.43-0.86; p < 0,001). Yet only the internal mammary nodes provide a benefit in DMFS (MS + WBI/CWI HR = 0.97; CI:0.81-1.16; p = 0.74 and IM + MS + WBI/CWI HR = 0.84; CI:0.75-0.94; p = 0.002). Conclusion Expanding the radiation field to the axillary apex and supraclavicular nodes after axillary node dissection reduced loco-regional recurrences without improvement in overall and cancer-specific survival. A prolongation in survival due to regional nodal irradiation is achieved when the internal mammary chain is included. This derives from a reduction in distant metastasis.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Balint Tamaskovics
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany.
| | - Stefanie Corradini
- Department of Radiation Oncology, LMU University of Munich, Munich, Germany
| | | | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
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18
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Mastectomy or Breast-Conserving Therapy for Early Breast Cancer in Real-Life Clinical Practice: Outcome Comparison of 7565 Cases. Cancers (Basel) 2019; 11:cancers11020160. [PMID: 30709048 PMCID: PMC6406394 DOI: 10.3390/cancers11020160] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/22/2019] [Accepted: 01/28/2019] [Indexed: 12/19/2022] Open
Abstract
Although the organ preservation strategy by breast-conserving surgery (BCS) followed by radiation therapy (BCT) has revolutionized the treatment approach of early stage breast cancer (BC), the choice between treatment options in this setting can still vary according to patient preferences. The aim of the present study was to compare the oncological outcome of mastectomy versus breast-conserving therapy in patients treated in a modern clinical setting outside of clinical trials. 7565 women diagnosed with early invasive BC (pT1/2pN0/1) between 1998 and 2014 were included in this study (median follow-up: 95.2 months). In order to reduce selection bias and confounding, a subgroup analysis of a matched 1:1 case-control cohort consisting of 1802 patients was performed (median follow-up 109.4 months). After adjusting for age, tumor characteristics and therapies, multivariable analysis for local recurrence-free survival identified BCT as an independent predictor for improved local control (hazard ratio [HR]:1.517; 95%confidence interval:1.092–2.108, p = 0.013) as compared to mastectomy alone in the matched cohort. Ten-year cumulative incidence (CI) of lymph node recurrences was 2.0% following BCT, compared to 5.8% in patients receiving mastectomy (p < 0.001). Similarly, 10-year distant-metastasis-free survival (89.4% vs. 85.5%, p = 0.013) was impaired in patients undergoing mastectomy alone. This translated into improved survival in patients treated with BCT (10-year overall survival (OS) estimates 85.3% vs. 79.3%, p < 0.001), which was also significant on multivariable analysis (p = 0.011). In conclusion, the present study showed that patients treated with BCS followed by radiotherapy had an improved outcome compared to radical mastectomy alone. Specifically, local control, distant control, and overall survival were significantly better using the conservative approach. Thus, as a result of the present study, physicians should encourage patients to receive BCS with radiotherapy rather than mastectomy, whenever it is medically feasible and appropriate.
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