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Bourgier C, Cowen D, Castan F, Lemanski C, Gourgou S, Rivera S, Labib A, Peignaux K, Blanc-Onfroy ML, Benyoucef A, Mege A, Douadi-Gaci Z, Racadot S, Latorzeff I, Schick U, Jacquot S, Massabeau C, Guilbert P, Geffrelot J, Ellis S, Lecouillard I, Breton-Callu C, Richard-Tallet A, Boulbair F, Cretin J, Belkacémi Y, Bons F, Azria D, Fenoglietto P. Quality assurance program and early toxicities in the phase III BONBIS randomized trial evaluating the role of a localized radiation boost in ductal carcinoma in situ. Radiother Oncol 2021; 164:57-65. [PMID: 34571090 DOI: 10.1016/j.radonc.2021.09.014] [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: 02/08/2021] [Revised: 09/15/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE To describe the quality assurance (QA) program and early toxicities in the phase III randomized trial BONBIS (NCT00907868) on the role of a localized radiation boost in ductal carcinoma in situ (DCIS). MATERIALS AND METHODS From November 2008 to July 2014, 2004 patients were randomized in arm A (only whole breast radiotherapy, WBRT) and arm B (WBRT + boost). The QA program involved 44 participant centers that performed the dummy run (DR). Compliance and uniformity of clinical target volume (CTV) delineations, and dose prescription and delivery according to the BONBIS trial radiotherapy guidelines were analyzed. Acute toxicities (during and up to 3 months after radiotherapy completion, NCI-CTCAE v3.0 classification) were evaluated in 1929 patients. RESULTS The differences in whole breast CTV (CTV1) and planning target volume (PTV1) were ≤10%, and the differences in boost CTV (CTV2) and PTV (PTV2) were ≥20% compared with the reference DR values; 95% of the prescribed dose encompassed 98.7% and 100% of the median CTV1 and CTV2. Grade ≥2 breast erythema (38.3% vs. 22.4% of grade 2 and 5.4% vs. 2.1% of grade 3, p < 0.001), grade ≥2 dermatitis (2.8% vs. 0.7%, p < 0.001), and grade 2 hyperpigmentation (6.9% vs. 3.6%, p = 0.005) were more frequent in arm B than arm A. No acute lung or cardiac toxicity was observed. Smoking history, large breast size, and large breast CTV were strong predictive factors of grade ≥2 acute skin toxicities. CONCLUSIONS The QA program showed deviations in breast and tumor bed delineation. The boost significantly increased acute skin toxicities.
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Affiliation(s)
- Celine Bourgier
- Univ Montpellier, Montpellier, France; Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France; Fédération Universitaire d'Oncologie Radiothérapie d'Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France
| | - Didier Cowen
- Aix Marseille Univ, APHM, Hôpital Timone-Hôpital Nord, Département de Radiothérapie, Marseille, France
| | - Florence Castan
- Unité de Biométrie, Institut régional du Cancer Montpellier (ICM), Montpellier, France
| | - Claire Lemanski
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France; Fédération Universitaire d'Oncologie Radiothérapie d'Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France
| | - Sophie Gourgou
- Unité de Biométrie, Institut régional du Cancer Montpellier (ICM), Montpellier, France
| | - Sofia Rivera
- Gustave Roussy, Département d'oncologie radiothérapie, Villejuif, France; Université Paris-Saclay, Inserm, U1030, Villejuif, France
| | | | - Karine Peignaux
- Département d'Oncologie Radiothérapie Centre Georges-François LECLERC, Dijon, France
| | | | - Ahmed Benyoucef
- Département de Radiothérapie et de Physique médicale, Centre Henri Becquerel, Rouen, France
| | - Alice Mege
- Sainte Catherine, Institut du Cancer Avignon-Provence, Avignon, France
| | | | | | - Igor Latorzeff
- Département de radiothérapie-oncologie, Clinique Pasteur, Toulouse, France
| | - Ulrike Schick
- Department of Radiation Oncology, University Hospital of Brest, UBO, LaTIM UMR 1101, Brest, France
| | - Stephane Jacquot
- Centre de Cancerologie du Grand Montpellier, Montpellier, France
| | - Carole Massabeau
- Département de Radiotherapie, Institut Claudius Regaud IUCT-O, Toulouse, France
| | | | - Julien Geffrelot
- Service de Radiothérapie, Centre François Baclesse, Caen, France
| | - Stephen Ellis
- Service de Radiothérapie, Centre Catalan d'Oncologie, Perpignan, France
| | | | | | - Agnès Richard-Tallet
- Institut Paoli-Calmettes, département d'Oncologie Radiothérapie, Marseille, France; Centre de Recherche en Cancérologie de Marseille (CRCM), INSERM UMR 1068, Marseille, France
| | | | | | - Yazid Belkacémi
- Department of Radiation Oncology and Henri Mondor Breast Center, AP HP - Henri Mondor University Hospital, University of Paris-Est (UPEC), INSERM Unit 955, Team 21-IMRB, Creteil, France
| | - Françoise Bons
- Fédération Universitaire d'Oncologie Radiothérapie d'Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France; Service de Radiothérapie, CHU Nîmes, France
| | - David Azria
- Univ Montpellier, Montpellier, France; Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France; Fédération Universitaire d'Oncologie Radiothérapie d'Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France
| | - Pascal Fenoglietto
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France; Fédération Universitaire d'Oncologie Radiothérapie d'Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France
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Recht A. Whole-Breast Irradiation Is the Preferred Standard of Care for the Majority of Patients With Early-Stage Breast Cancer. J Clin Oncol 2020; 38:2263-2267. [PMID: 32442072 DOI: 10.1200/jco.19.02388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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3
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Serban M, Lambert C, Ruo R, Maietta C, Parker W, Evans M, Hijal T. Computed tomography-based virtual simulation versus ultrasound-based clinical setup in electron breast boost radiotherapy: Methodology for CT-based electron virtual simulation. Phys Med 2019; 67:100-106. [PMID: 31704390 DOI: 10.1016/j.ejmp.2019.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/06/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To compare clinical setup using ultrasound (U/S)-delineated target versus computed tomography (CT) virtual simulation using CT-outlined target in breast electron boost. To describe a methodology for electron virtual simulation and collision testing with the treatment planning system (TPS). METHODS The two techniques were compared in a prospective study on 12 patients, who were treated using a clinical setup. Target definition was performed by both U/S and CT imaging. The U/S-based target was made visible on CT images by placing a radio-opaque wire on U/S skin markings. The dose distribution of the clinical setup was reproduced in the TPS using the actual electron patient treatment parameters. A CT-based TPS virtual simulation/dose optimization was compared to the clinical setup technique. RESULTS Mean beam aperture was larger by 16.3 cm2 (p = 0.011) for U/S compared to CT-outlined target. Target mean depth difference (CT minus U/S) was 0.03 cm (p = 0.875). Target coverage at depth was adequate in all cases with CT-based simulation while under/overcovering the target at depth by more than 5 mm in 2 out of 12 cases with clinical setup. Mean target V90% was 98.5% (CT-based simulation) and 84.4% (clinical setup). Ipsilateral lung/breast were better spared with CT-based simulation. To date, the methodology for CT virtual simulation was applied on 152 patients and collision was avoided in all cases. CONCLUSIONS CT-based simulation and target delineation allows for improved definition of the en-face electron field with less amount of normal tissue irradiated while including the entire target with an adequate margin and optimal electron energy.
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Affiliation(s)
- Monica Serban
- Department of Medical Physics, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada.
| | - Christine Lambert
- Department of Radiation Oncology, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - Russell Ruo
- Department of Medical Physics, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - Ciro Maietta
- Department of Radiation Oncology, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - William Parker
- Department of Medical Physics, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - Michael Evans
- Department of Medical Physics, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - Tarek Hijal
- Department of Radiation Oncology, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
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4
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Improvement of consistency in delineating breast lumpectomy cavity using surgical clips. J Surg Res 2018; 221:30-34. [DOI: 10.1016/j.jss.2017.07.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 07/12/2017] [Accepted: 07/21/2017] [Indexed: 11/22/2022]
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5
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Lin JY, Bluebond-Langner R, Choi E, Cheston S, Nichols EM, Cohen RJ, Bentzen SM, Drogula C, Kesmodel S, Bellavance E, Rosenblatt P, Tkaczuk K, Slezak S, Feigenberg SJ. Effect of reduction mammoplasty on acute radiation side effects and use of lumpectomy cavity boosts. Pract Radiat Oncol 2017; 7:e299-e308. [DOI: 10.1016/j.prro.2017.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/02/2017] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
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Landry A, Berrang T, Gagne I, Popescu C, Mitchell T, Vey H, Sand L, Soh SY, Wark J, Olivotto I, Beckham W. Investigation of variability in image acquisition and contouring during 3D ultrasound guidance for partial breast irradiation. Radiat Oncol 2014; 9:35. [PMID: 24467876 PMCID: PMC3996185 DOI: 10.1186/1748-717x-9-35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 01/09/2014] [Indexed: 12/02/2022] Open
Abstract
Background Three-dimensional ultrasound (3DUS) at simulation compared to 3DUS at treatment is an image guidance option for partial breast irradiation (PBI). This study assessed if user dependence in acquiring and contouring 3DUS (operator variability) contributed to variation in seroma shifts calculated for breast IGRT. Methods Eligible patients met breast criteria for current randomized PBI studies. 5 Operators participated in this study. For each patient, 3 operators were involved in scan acquisitions and 5 were involved in contouring. At CT simulation (CT1), a 3DUS (US1) was performed by a single radiation therapist (RT). 7 to 14 days after CT1 a second CT (CT2) and 3 sequential 3DUS scans (US2a,b,c) were acquired by each of 3 RTs. Seroma shifts, between US1 and US2 scans were calculated by comparing geometric centers of the seromas (centroids). Operator contouring variability was determined by comparing 5 RT’s contours for a single image set. Scanning variability was assessed by comparing shifts between multiple scans acquired at the same time point (US1-US2a,b,c). Shifts in seromas contoured on CT (CT1-CT2) were compared to US data. Results From an initial 28 patients, 15 had CT visible seromas, met PBI dosimetric constraints, had complete US data, and were analyzed. Operator variability contributed more to the overall variability in seroma localization than the variability associated with multiple scan acquisitions (95% confidence mean uncertainty of 6.2 mm vs. 1.1 mm). The mean standard deviation in seroma shift was user dependent and ranged from 1.7 to 2.9 mm. Mean seroma shifts from simulation to treatment were comparable to CT. Conclusions Variability in shifts due to different users acquiring and contouring 3DUS for PBI guidance were comparable to CT shifts. Substantial inter-observer effect needs to be considered during clinical implementation of 3DUS IGRT.
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Affiliation(s)
- Anthony Landry
- Radiation Therapy Program, Prince Edward Island Cancer Treatment Centre, Charlottetown, PE, Canada.
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Bourgier C, Aimard L, Bodez V, Bollet MA, Cutuli B, Franck D, Hennequin C, Kirova YM, Azria D. Adjuvant radiotherapy in the management of axillary node negative invasive breast cancer: a qualitative systematic review. Crit Rev Oncol Hematol 2012; 86:33-41. [PMID: 23088955 DOI: 10.1016/j.critrevonc.2012.09.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 08/06/2012] [Accepted: 09/25/2012] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To actualize and to detail guidelines used in technical radiotherapy and indications for innovative radiation technologies in early axillary node negative breast cancer (BC). METHODS Dosimetric and treatment planning studies, phase II and III trials, systematic reviews and retrospective studies were all searched (Medline(®) database). Their quality and clinical relevance were also checked against validated checklists. A level of evidence was associated for each result. RESULTS A total of 75 references were included. Adjuvant BC radiotherapy (50Gy/25 fractions/5 weeks followed by a tumor boost of 16Gy/8 fractions) is still the standard of care. Overall treatment time could be shortened for patients who present with low local relapse risk BC by using either hypofractionated whole breast irradiation; or accelerated partial breast irradiation. BC IMRT is not used in current practice. CONCLUSION Our group aimed to provide guidelines for technical and clinical applications of innovative BC radiation technologies.
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Affiliation(s)
- C Bourgier
- Radiation Oncology Department, Institut Gustave Roussy, Villejuif, France.
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Venables K, Tsang Y, Ciurlionis L, Coles CE, Yarnold JR. Does participation in clinical trials influence the implementation of new techniques? A look at changing techniques in breast radiotherapy in the UK. Clin Oncol (R Coll Radiol) 2012; 24:e100-5. [PMID: 22795830 DOI: 10.1016/j.clon.2012.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 04/13/2012] [Accepted: 06/22/2012] [Indexed: 10/28/2022]
Abstract
AIMS To examine the effect of UK breast radiotherapy trials on the adoption of new radiotherapy techniques over the last 15 years. MATERIALS AND METHODS The data were taken from questionnaires returned to the national radiotherapy quality assurance team for each of the major trials (START, Supremo, FAST, IMPORT) with additional information sought from heads of radiotherapy physics departments where needed. RESULTS The peak years for the introduction of three-dimensional radiotherapy corresponded to the opening of new trials requiring these techniques. Some non-trial centres had still not implemented three-dimensional techniques for breast cancer patients at the time the most recent questionnaire was completed (2009). CONCLUSION Clinical trials provide the framework and impetus for introducing more accurate radiotherapy for UK women with early breast cancer.
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Affiliation(s)
- K Venables
- National Trials QA Team, Mount Vernon Hospital, Northwood, UK.
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9
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Ten-year results of a phase II study with a single fraction of high-dose-rate brachytherapy (FAST-boost) after whole breast irradiation in invasive breast carcinoma. Clin Transl Oncol 2012; 14:109-15. [DOI: 10.1007/s12094-012-0769-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Oden S, Thureau S, Baron M, Hanzen C. Traitement conservateur du cancer du sein : optimisation du repérage du lit tumoral. IMAGERIE DE LA FEMME 2011. [DOI: 10.1016/j.femme.2011.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Has Placement of Surgical Clips in the Lumpectomy Bed Fallen Out of Favor? Indian J Surg Oncol 2011. [DOI: 10.1007/s13193-011-0089-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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12
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Azu M, Goyal S, Patel U, Haffty B, Kearney T. Has Placement of Surgical Clips in the Lumpectomy Bed Fallen Out of Favor? Ann Surg Oncol 2011; 18:1529-32. [DOI: 10.1245/s10434-011-1672-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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13
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Wong P, Muanza T, Reynard E, Robert K, Barker J, Sultanem K. Use of Three-Dimensional Ultrasound in the Detection of Breast Tumor Bed Displacement During Radiotherapy. Int J Radiat Oncol Biol Phys 2011; 79:39-45. [DOI: 10.1016/j.ijrobp.2009.10.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 09/08/2009] [Accepted: 10/12/2009] [Indexed: 12/20/2022]
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Kirova YM, Castro Pena P, Hijal T, Fournier-Bidoz N, Laki F, Sigal-Zafrani B, Dendale R, Bollet MA, Campana F, Fourquet A. Improving the definition of tumor bed boost with the use of surgical clips and image registration in breast cancer patients. Int J Radiat Oncol Biol Phys 2010; 78:1352-5. [PMID: 20381975 DOI: 10.1016/j.ijrobp.2009.10.049] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 09/10/2009] [Accepted: 10/13/2009] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate the accuracy of a boost technique. METHODS AND MATERIALS Twenty-two patients underwent tumorectomy with placement of two or more clips in the surgical cavity before breast remodeling. Preoperative and postoperative computed tomography scans, with match-point registration, were performed on all patients. The relationship between the location of the gross tumor volume (GTV), defined on the preoperative scan, and clip clinical target volume (CTV) (clips with a 5-mm margin on the postoperative scan) was then studied, by use of commercial volume analysis software. RESULTS Of the patients, 4 had two clips, 2 had three clips, 8 had four clips, and 8 had five clips. The median GTV was 1.06 mL (range, 0.2-5.3 mL); clip CTV ranged from 2.4 to 21.5 mL. Volumetric analysis showed that in 7 cases (32%), there was no intersection between the GTV and the clip CTV, with the following distribution: 4 patients with two clips, 1 patient with three clips, 1 patient with four clips, and 1 patient with five clips. The common contoured volume was defined as the percent ratio between the intersection of the GTV and clip CTV and the GTV. It was found to be significantly increased if three or more clips were used vs. only two clips (common contoured volume, 35.45% vs. 0.73%; p = 0.028). Finally, the GTV and clip CTV volume relationship can be presented as follows: 12.5% to 33% overlap in 8 patients (36.4%), 50% to 75% in 5 patients (22.7%), and greater than 90% in 2 patients (9%). CONCLUSIONS The use of three or more clips during tumorectomy increases the accuracy of tumor bed delineation.
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Affiliation(s)
- Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France.
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15
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Oden S, Thureau S, Baron M, Hanzen C. Traitement conservateur du cancer du sein : optimisation du repérage du lit tumoral. Cancer Radiother 2010; 14:96-102. [DOI: 10.1016/j.canrad.2009.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 10/16/2009] [Accepted: 11/15/2009] [Indexed: 11/17/2022]
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Dzhugashvili M, Pichenot C, Dunant A, Balleyguier C, Delaloge S, Mathieu MC, Garbay JR, Marsiglia H, Bourgier C. Surgical Clips Assist in the Visualization of the Lumpectomy Cavity in Three-Dimensional Conformal Accelerated Partial-Breast Irradiation. Int J Radiat Oncol Biol Phys 2010; 76:1320-4. [PMID: 19596169 DOI: 10.1016/j.ijrobp.2009.04.089] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 03/30/2009] [Accepted: 04/03/2009] [Indexed: 11/19/2022]
Affiliation(s)
- Maia Dzhugashvili
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
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17
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Dzhugashvili M, Tournay E, Pichenot C, Dunant A, Pessoa E, Khallel A, Gouy S, Uzan C, Garbay JR, Rimareix F, Spielmann M, Vielh P, Marsiglia H, Bourgier C. 3D-conformal accelerated partial breast irradiation treatment planning: the value of surgical clips in the delineation of the lumpectomy cavity. Radiat Oncol 2009; 4:70. [PMID: 20042124 PMCID: PMC2808304 DOI: 10.1186/1748-717x-4-70] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 12/31/2009] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Accurate localisation of the lumpectomy cavity (LC) volume is one of the most critical points in 3D-conformal Partial breast irradiation (3D-APBI) treatment planning because the irradiated volume is restricted to a small breast volume. Here, we studied the role of the placement of surgical clips at the 4 cardinal points of the lumpectomy cavity in target delineation. METHODS Forty CT-based 3D-APBI plans were retrieved on which a total of 4 radiation oncologists, two trainee and two experienced physicians, outlined the lumpectomy cavity. The inter-observer variability of LC contouring was assessed when the CTV was defined as the delineation that encompassed both surgical clips and remodelled breast tissue. RESULTS The conformity index of tumour bed delineation was significantly improved by the placement of surgical clips within the LC (median at 0.65). Furthermore, a better conformity index of LC was observed according to the experience of the physicians (median CI = 0.55 for trainee physicians vs 0.65 for experienced physicians). CONCLUSIONS The placement of surgical clips improved the accuracy of lumpectomy cavity delineation in 3D-APBI. However, a learning curve is needed to improve the conformity index of the lumpectomy cavity.
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Affiliation(s)
- Maia Dzhugashvili
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Elodie Tournay
- Biostatistics, and Epidemiology Unit, Institut Gustave Roussy, Villejuif, France
| | | | - Ariane Dunant
- Biostatistics, and Epidemiology Unit, Institut Gustave Roussy, Villejuif, France
| | - Eduardo Pessoa
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Adel Khallel
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Sébastien Gouy
- Department of Breast Surgery, Institut Gustave Roussy, Villejuif, France
| | - Catherine Uzan
- Department of Breast Surgery, Institut Gustave Roussy, Villejuif, France
| | - Jean-Rémy Garbay
- Department of Breast Surgery, Institut Gustave Roussy, Villejuif, France
| | - Françoise Rimareix
- Department of Breast Surgery, Institut Gustave Roussy, Villejuif, France
| | - Marc Spielmann
- Department of Breast Oncology, Institut Gustave Roussy, Villejuif, France
| | - Philippe Vielh
- Department of Pathology, Institut Gustave Roussy, Villejuif, France
| | - Hugo Marsiglia
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
- University of Florence, Italy
| | - Céline Bourgier
- Department of Radiation Oncology, Institut Gustave Roussy, Villejuif, France
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Berrang TS, Truong PT, Popescu C, Drever L, Kader HA, Hilts ML, Mitchell T, Soh SY, Sands L, Silver S, Olivotto IA. 3D Ultrasound Can Contribute to Planning CT to Define the Target for Partial Breast Radiotherapy. Int J Radiat Oncol Biol Phys 2009; 73:375-83. [PMID: 18692322 DOI: 10.1016/j.ijrobp.2008.04.041] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 04/15/2008] [Accepted: 04/17/2008] [Indexed: 11/16/2022]
Affiliation(s)
- Tanya S Berrang
- Radiation Therapy Program, British Columbia Cancer Agency, Vancouver Island Centre, Victoria, BC, Canada
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Kader HA, Truong PT, Pai R, Panades M, Jones S, Ansbacher W, Olivotto IA. When Is CT-Based Postoperative Seroma Most Useful to Plan Partial Breast Radiotherapy? Evaluation of Clinical Factors Affecting Seroma Volume and Clarity. Int J Radiat Oncol Biol Phys 2008; 72:1064-9. [PMID: 18411005 DOI: 10.1016/j.ijrobp.2008.02.049] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 02/14/2008] [Accepted: 02/15/2008] [Indexed: 10/22/2022]
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20
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Mannino M, Yarnold JR. Local relapse rates are falling after breast conserving surgery and systemic therapy for early breast cancer: can radiotherapy ever be safely withheld? Radiother Oncol 2008; 90:14-22. [PMID: 18502528 DOI: 10.1016/j.radonc.2008.05.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 05/01/2008] [Indexed: 11/30/2022]
Abstract
Rates of local tumour relapse after breast conservation treatment in women with early breast cancer are falling. Explanations for this decline are considered in this review including advances in breast cancer management and aging of the breast cancer population. Breast surgery has become more standardised following publication of practice guidelines and is mostly carried out by specialist surgeons. Systemic therapies (hormonal therapy and chemotherapy) are now more effective and are recommended to a higher proportion of patients than ever before. Radiotherapy techniques have also improved. The contributions of each factor are difficult to quantify precisely, but all are likely to be relevant. In order to identify a subgroup of women that might safely be spared radiotherapy, several factors are analysed, including the prognostic significance for local relapse of tumour characteristics (pathologic data, gene-expression profiles), patient characteristics and life expectancy (age and comorbidities).
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Affiliation(s)
- Mariella Mannino
- Royal Marsden Hospital, Department of Clinical Oncology, Surrey, UK
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21
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Kirova YM, Fournier-Bidoz N, Servois V, Laki F, Pollet GA, Salmon R, Thomas A, Dendale R, Bollet MA, Campana F, Fourquet A. How to boost the breast tumor bed? A multidisciplinary approach in eight steps. Int J Radiat Oncol Biol Phys 2008; 72:494-500. [PMID: 18374516 DOI: 10.1016/j.ijrobp.2007.12.059] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 12/18/2007] [Accepted: 12/19/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE To describe a new procedure for breast radiotherapy that will improve tumor bed localization and radiotherapy treatment using a multidisciplinary approach. PATIENTS AND METHODS This pilot study was conducted by departments of radiation oncology, surgery, and radiology. A new procedure has been implemented, summarized as eight steps: from pre-surgery contrast CT to surgery, tumor bed planning target volume (PTV) determination, and finally breast and tumor bed irradiation. RESULTS Twenty patients presenting with T1N0M0 tumors were enrolled in the study. All patients underwent lumpectomy with the placement of surgical clips in the tumor bed region. During surgery, 1 to 5 clips were placed in the lumpectomy cavity before the plastic procedure. All patients underwent pre- and postoperative CT scans in the treatment position. The two sets of images were registered with a match-point registration. All volumes were contoured and the results evaluated. The PTV included the clips region, the gross tumor volume, and the surgical scar, with an overall margin of 5-10 mm in all directions, corresponding to localization and setup uncertainties. For each patient the boost PTV was discussed and compared with our standard forward-planned PTV. CONCLUSIONS We demonstrate the feasibility of a tumor bed localization and treatment procedure that seems adaptable to routine practice. Our study shows the advantages of a multidisciplinary approach for tumor bed localization and treatment. The use of more than 1 clip associated with pre- to postoperative CT image registration allows better definition of the PTV boost volume.
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Affiliation(s)
- Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France.
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22
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Fatunase T, Wang Z, Yoo S, Hubbs JL, Prosnitz RG, Yin FF, Marks LB. Assessment of the Residual Error in Soft Tissue Setup in Patients Undergoing Partial Breast Irradiation: Results of a Prospective Study Using Cone-Beam Computed Tomography. Int J Radiat Oncol Biol Phys 2008; 70:1025-34. [PMID: 17892919 DOI: 10.1016/j.ijrobp.2007.07.2344] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 07/10/2007] [Accepted: 07/13/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE On-board cone-beam computed tomography (CBCT) provides soft tissue information that may improve setup accuracy in patients undergoing accelerated partial breast irradiation (APBI). We used CBCT to assess the residual error in soft tissue after two-dimensional kV/MV alignment based on bony anatomy. We also assessed the dosimetric impact of this error. METHODS AND MATERIALS Ten patients undergoing APBI were studied as part of an institutional review board-approved prospective trial. Patients were aligned based on skin/cradle marks plus orthogonal kV/MV images registered based on bony landmarks to digitally reconstructed radiographs from the planning CT. A subsequent CBCT was registered to the planning CT using soft tissue information. This "residual error" and its dosimetric impact was measured. RESULTS The root-mean-square of the residual error was 3, 4, and 4 mm, in the right-left, anterior-posterior, and superior-inferior directions, respectively. The average vector sum was 6+/-2 mm. Average reductions in mean dose to the lumpectomy cavity, clinical target volume (CTV), and planning target volume were 0.1%, 0.4%, and 1%, respectively. The mean difference in the clinical target and planning target volumes that received 95% of the prescribed dose (V95) were 1% and 4%. CONCLUSIONS In this initial study with a modest number of patients, the residual error in soft tissue was typically <5 mm, and with the field margins used, the resultant dosimetric consequences were modest. In patients immobilized in a customized cradle, setup using orthogonal kV images thus appears accurate and reproducible. The CBCT technique may have particular utility in patients with larger breast volumes or breast deformations. Further studies involving larger numbers of patients are needed to further assess the utility of CBCT.
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Affiliation(s)
- Toyosi Fatunase
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA
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Bates AT, Swift CL, Kwa W, Moravan V, Aquino-Parsons C. A Computed Tomography-based Protocol vs Conventional Clinical Mark-up for Breast Electron Boost. Clin Oncol (R Coll Radiol) 2007; 19:349-55. [PMID: 17379487 DOI: 10.1016/j.clon.2007.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Revised: 01/15/2007] [Accepted: 02/02/2007] [Indexed: 11/23/2022]
Abstract
AIMS Computed tomography planning of whole breast radiotherapy (WBRT) improves breast coverage and reduces the normal tissue dose. Computed tomography planning may increase tumour bed boost treatment accuracy. The aims of this investigation were (1) to compare the breast boost volume treated with clinical mark-up with the volume delineated with computed tomography planning and (2) to study tumour bed volume changes between the initial planning computed tomography scan and a second computed tomography scan at the time of breast boost mark-up. MATERIALS AND METHODS Women receiving adjuvant WBRT and an electron boost after breast-conserving surgery were eligible. As per standard practice, WBRT was computed tomography planned while the boost electron portal was clinically defined. Electron field borders were then traced with wire and a second computed tomography scan was carried out in the boost treatment position. Post-surgical radiological abnormalities were contoured to create a tumour bed clinical target volume (CTV) on both scans (CTV1 and CTV2). A 1cm margin to CTV2 defined the planning target volume (PTV). The proportions of the CTV2 and PTV receiving 90% (V90) and 80% (V80) of the dose were calculated. Changes in volume between CTV1 and CTV2 were analysed. RESULTS Data from 47 eligible patients were analysed. The mean V90 for the PTV was 61%. Lower electron energy (P<0.001) and small field sizes (P=0.004) were associated with a low V90. The mean CTV decreased by 4.3 cm3 (P=0.014) and was smaller in those with a long surgery to computed tomography interval (P=0.008). On average, the 90% isodose covered 61 cm3 of normal tissue. CONCLUSIONS Conventional clinical breast boost planning is inaccurate. Electron boost computed tomography planning together with appropriate surgical clip placement and the use of mammograms and pathological information should provide optimal coverage of the tumour site. The boost could usually be planned from the initial computed tomography scan.
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Affiliation(s)
- A T Bates
- Department of Clinical Oncology, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK, and Department of Medical Physics, British Columbia Cancer Agency, University of British Columbia, Vancouver, Canada.
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Oh KS, Kong FM, Griffith KA, Yanke B, Pierce LJ. Planning the breast tumor bed boost: changes in the excision cavity volume and surgical scar location after breast-conserving surgery and whole-breast irradiation. Int J Radiat Oncol Biol Phys 2006; 66:680-6. [PMID: 16863683 DOI: 10.1016/j.ijrobp.2006.04.042] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 04/11/2006] [Accepted: 04/16/2006] [Indexed: 12/28/2022]
Abstract
PURPOSE The aims of this study were to determine the changes in breast and excision cavity volumes after whole-breast irradiation and the adequacy of using the surgical scar to guide boost planning. METHODS AND MATERIALS A total of 30 women consecutively treated for 31 breast cancers were included in this study. Simulation CT scans were performed before and after whole-breast irradiation. CT breast volumes were delineated using clinically defined borders. Excision cavity volumes were contoured based on surgical clips, the presence of a hematoma, and/or other surgical changes. Hypothetical electron boost plans were generated using the surgical scar with a 3-cm margin and analyzed for coverage. RESULTS The mean CT breast volumes were 774 and 761 cc (p = 0.22), and the excision cavity volumes were 32.1 and 25.1 cc (p < 0.0001), before and after 40 Gy (39-42 Gy) of whole-breast irradiation, respectively. The volume reduction in the excision cavity was inversely correlated with time elapsed since surgery (R = 0.46, p < 0.01) and body weight (R = 0.50, p < 0.01). The scar-guided hypothetical plans failed to cover the excision cavity adequately in 62% and 53.8% of cases using the pretreatment and postradiation CTs, respectively. Per the hypothetical plans, the minimum dose to the excision cavity was significantly lower for tumors located in the inner vs. outer quadrants (p = 0.02) and for cavities >20 cc vs. <20 cc (p = 0.01). CONCLUSIONS This study demonstrates a significant reduction in the volume of the excision cavity during whole-breast irradiation. Scar-guided boost plans provide inadequate coverage of the excision cavity in the majority of cases.
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Affiliation(s)
- Kevin S Oh
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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25
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Raj KA, Evans ES, Prosnitz RG, Quaranta BP, Hardenbergh PH, Hollis DR, Light KL, Marks LB. Is There an Increased Risk of Local Recurrence Under the Heart Block in Patients with Left-Sided Breast Cancer? Cancer J 2006; 12:309-17. [PMID: 16925976 DOI: 10.1097/00130404-200607000-00010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Tangential radiotherapy for left-sided breast cancer may be cardiotoxic. Shaping the field with a heart block reduces cardiac exposure but may under-dose the breast and/or chest wall. We compared the incidence and location of local recurrences in patients irradiated with and without a heart block. METHODS AND MATERIALS Between 1994 and 1998, 180 patients irradiated to the left breast and/or chest wall were retrospectively reviewed. The local recurrence rates in patients treated with and without a heart block were compared using a 2-tailed Fisher exact test. An in-depth dosimetric analysis was performed in 23 patients to assess the percentage of breast tissue under-dosed by inclusion of the heart block. RESULTS Overall, the local recurrence rates in patients with or without a heart block were similar. In postlumpectomy patients with inferiorly located tumors, the rates of local recurrence with and without a heart block were 2 of 6 patients versus 0 of 19 patients, respectively. In the dosimetric analysis, the average percentage of breast tissue under-dosed by the inclusion of a heart block was 2.8% (range, 0%-11%). DISCUSSION A heart block is a reasonable method to limit cardiac dose but should be used cautiously following a lumpectomy in patients with inferiorly located tumors. Additional study with larger numbers of patients is warranted.
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MESH Headings
- Breast Neoplasms/pathology
- Breast Neoplasms/physiopathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/physiopathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Female
- Heart Block/etiology
- Heart Block/physiopathology
- Humans
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local/physiopathology
- Radiotherapy/methods
- Radiotherapy Dosage
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Affiliation(s)
- Katelyn A Raj
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina 27710, USA
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26
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Graham P, Fourquet A. Placing the boost in breast-conservation radiotherapy: A review of the role, indications and techniques for breast-boost radiotherapy. Clin Oncol (R Coll Radiol) 2006; 18:210-9. [PMID: 16605052 DOI: 10.1016/j.clon.2005.11.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Randomised trials have established that the addition of a boost dose of radiotherapy to the lumpectomy site after whole-breast adjuvant radiotherapy further improves local control achieved by whole-breast radiotherapy alone. The absolute size of this benefit varies according to the baseline risk of local recurrence. Age is the strongest predictor of benefit. Below the age of 40 years, the absolute benefit of a boost seems to be substantial, and there are no clearly identified groups unlikely to benefit. Above the age of 50 years, the benefit is small, and several additional risk factors for local failure would need to be present to merit boost treatment. These may include tumour size, high grade, high mitotic rate, lymphovascular invasion, extensive and high grade associated with intraduct carcinoma, receptor-positive tumours when avoidance of anti-oestrogen therapy is desired or receptor-negative tumours. Other independent reasonable indications for the use of a boost would be positive margins where further surgery is not indicated. If a boost is indicated, a variety of techniques may be used and toxicity and cosmetic results remain highly acceptable. Overall, there seems to be no substantial differences in boost technique results; however, interstitial techniques may have advantages for deeper targets compared with electrons. Irrespective of technique, accurate localisation will maximise the benefit of a boost. Surgical clips are strongly recommended to facilitate localisation.
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Affiliation(s)
- P Graham
- Cancer Care Centre, St George Hospital, Kogarah, Australia.
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27
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28
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Lemanski C, Azria D, Thezenas S, Gutowski M, Saint-Aubert B, Rouanet P, Fenoglietto P, Ailleres N, Dubois JB. Intraoperative radiotherapy given as a boost for early breast cancer: long-term clinical and cosmetic results. Int J Radiat Oncol Biol Phys 2006; 64:1410-5. [PMID: 16442241 DOI: 10.1016/j.ijrobp.2005.10.025] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2005] [Revised: 10/31/2005] [Accepted: 10/31/2005] [Indexed: 01/22/2023]
Abstract
PURPOSE The standard radiotherapy (RT) of breast cancer consists of 50 Gy external beam RT (EBRT) to the whole breast followed by an electron boost of 10-16 Gy to the tumor bed, but this has several cosmetic disadvantages. Intraoperative radiotherapy (IORT) could be an alternative to overcome these. METHODS AND MATERIALS We evaluated 50 women with early breast cancer operated on in a dedicated IORT facility. Median dose of 10 Gy was delivered using 9-MeV electron beams. All patients received postoperative EBRT (50 Gy in 2 Gy fractions). Late toxicity and cosmetic results were assessed independently by two physicians according to the Common Terminology Criteria for Adverse Event v3.0 grading system and the European Organization for Research and Treatment of Cancer questionnaires. RESULTS After a median follow-up of 9.1 years (range, 5-15 years), two local recurrences were observed within the primary tumor bed. At the time of analysis, 45 patients are alive with (n = 1) or without disease. Among the 42 disease-free remaining patients, 6 experienced Grade 2 late subcutaneous fibrosis within the boost area. Overall, the scores indicated a very good quality of life and cosmesis was good to excellent in the evaluated patients. CONCLUSION Our results confirm that IORT given as a boost after breast-conserving surgery is a reliable alternative to conventional postoperative fractionated boost radiation.
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Affiliation(s)
- Claire Lemanski
- Department of Radiation Oncology, Val d'Aurelle Cancer Institute, Montpellier, France
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29
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Goldberg H, Prosnitz RG, Olson JA, Marks LB. Definition of postlumpectomy tumor bed for radiotherapy boost field planning: CT versus surgical clips. Int J Radiat Oncol Biol Phys 2005; 63:209-13. [PMID: 16111591 DOI: 10.1016/j.ijrobp.2005.01.044] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2004] [Revised: 01/13/2005] [Accepted: 01/20/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare the location and extent of the tumor bed as defined by surgical clips and computed tomography (CT) scans, after lumpectomy, for electron boost planning as part of breast radiotherapy. METHODS AND MATERIALS Planning CT images of 31 operated breasts in 30 patients who underwent lumpectomy were reviewed. One or more clips were placed in the lumpectomy cavity. Serial CT images were used to measure the depth and transverse and longitudinal dimensions. The area and geometric center of the tumor bed were defined by the clips and CT. RESULTS The CT and clip measurements were identical for the maximal tumor depth in 27 of 30 patients. The CT bed extended beyond the clips by 0-7 mm medially in the transverse/longitudinal extent (multiclip patients). The median distance between the geometric centers in the coronal plane for the tumor bed center was larger for patients with single clips than for those with multiple clips (p < 0.025). Tumor bed areas in the coronal plane defined by both methods correlated strongly. However, the CT-defined area was larger by 13.9 mm2. The CT bed was more readily visible in patients with a shorter interval between surgery and radiotherapy. CONCLUSION The maximal depth of the tumor bed was similar using the two methods. The extent and centers of the clip-and CT-determined beds differed significantly. This may indicate an underestimation of the tumor bed as defined by clips only and justifies integration of CT information in boost field planning.
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MESH Headings
- Adult
- Aged
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma in Situ/diagnostic imaging
- Carcinoma in Situ/radiotherapy
- Carcinoma in Situ/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Electrons/therapeutic use
- Female
- Humans
- Mastectomy, Segmental
- Middle Aged
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Adjuvant
- Surgical Instruments
- Tomography, X-Ray Computed
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30
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Warszawski A, Baumann R, Karstens JH. Sonographic guidance for electron boost planning after breast-conserving surgery. JOURNAL OF CLINICAL ULTRASOUND : JCU 2004; 32:333-337. [PMID: 15293299 DOI: 10.1002/jcu.20050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE This study was conducted to determine the feasibility of using sonography for electron boost planning in breast cancer treatment and to define the factors that influence the accuracy and reproducibility of this technique. PATIENTS AND METHODS Seventy-seven patients underwent 102 sonographic examinations after breast-conserving surgery and before and after radiotherapy. The size of the electron boost field was defined by measuring the postoperative cavity. Reproducibility of the sonographic findings was investigated in 25 of the patients who were examined before and after radiotherapy (at a total dose of 46-50.4 Gy). Depth (distance from the skin surface to the posterior aspect of the postoperative cavity) was measured, and sonographic appearance of the postoperative cavity was evaluated. Type of surgical procedure, time elapsed since surgery, use of systemic therapy, menopausal status, breast size, and radiation dose were investigated for their influence on sonographic appearance and visualization of the postoperative cavity. RESULTS The postoperative cavity was well visualized in 78% of patients and visualized with some difficulty in 22%. In all but 5 patients, it was hypoechoic and inhomogeneous. The mean depth of the postoperative cavity after radiotherapy was 27 +/- 4 mm. Smaller breast (p < 0.001) and younger age (p < 0.05) were associated with decreased visibility of the postoperative cavity. Sonographic appearance was the same before and after radiotherapy, but the mean difference in postoperative cavity depth between the 2 measurements was 2 mm (range, 0-4 mm). In 43/77 (56%) of the patients, changes in electron energy or in field size were required after sonographic measurement. CONCLUSION Sonography is a useful and reproducible means of electron boost planning, helping to avoid underdosage of the postoperative cavity and overdosage of normal tissue.
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Affiliation(s)
- Antje Warszawski
- Department of Radiotherapy and Special Oncology, Medical University Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
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31
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McEntee MC, Samii VF, Walsh P, Hornof WJ. Postoperative Assessment of Surgical Clip Position in 16 Dogs With Cancer: A Pilot Study. J Am Anim Hosp Assoc 2004; 40:300-8. [PMID: 15238560 DOI: 10.5326/0400300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Metallic hemoclips or surgical staples were inserted in 16 tumor-bearing dogs at the time of surgical resection of the tumor. Orthogonal radiographs were taken immediately postoperatively and after wound healing to visualize the location and number of hemoclips or metallic staples. A shift in hemoclip/staple position was identified in nine dogs, mainly from positioning during radiography. In three dogs, an absolute shift in marker position was identified. Based on this study, it appears that the placement of surgical clips is potentially useful in identifying the tumor bed, which may be of benefit in establishing radiation treatment fields.
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Affiliation(s)
- Margaret C McEntee
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, California 95616, USA
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32
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Ringash J, Whelan T, Elliott E, Minuk T, Sanders K, Lukka H, Reiter H. Accuracy of ultrasound in localization of breast boost field. Radiother Oncol 2004; 72:61-6. [PMID: 15236875 DOI: 10.1016/j.radonc.2004.03.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2003] [Revised: 03/10/2004] [Accepted: 03/16/2004] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE To prospectively compare diagnostic ultrasound to the 'gold standard' of surgical clips for localization of the lumpectomy site for electron boost irradiation. PATIENTS AND METHODS Consecutive breast cancer patients referred following lumpectomy underwent diagnostic ultrasound in radiation treatment position 21-100 days post-surgery. All patients had 3-6 surgical clips defining the excision cavity. The site was marked on the skin and depth was measured. Target depth was the deepest aspect of the cavity plus a 1 cm deep margin. Treatment fields were prescribed with a 2 cm margin on the cavity, and electron energy was chosen to cover the target depth. Surgical clip position was assessed on orthogonal simulator films. RESULTS Localizations were performed in 54 breasts (52 women). The mean interval post-surgery was 53 (SD 17) days. Overall, 35/54 (65%) of localizations were adequate, 15/54 (28%) were marginal and 4/54 (7%) were inadequate. Regression showed that lower patient weight (r=-0.37, P=0.006) predicted adequacy of localization, with better accuracy in lighter women. CONCLUSIONS The accuracy rate for ultrasound exceeds the 20-50% reported for clinical localization. Diagnostic ultrasound may be used to improve the accuracy when surgical clips are not present.
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Affiliation(s)
- Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Hospital and University of Toronto, 610 University Avenue, Toronto, ON, Canada M5G 2M9
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33
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Kokubo M, Mitsumori M, Yamamoto C, Fujishiro S, Mise K, Kodama H, Nagata Y, Hiraoka M. Impact of boost irradiation with surgically placed radiopaque clips on local control in breast-conserving therapy. Breast Cancer 2002; 8:222-8. [PMID: 11668244 DOI: 10.1007/bf02967512] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study was to determine whether boost irradiation relying on radiopaque clips placed surgically around the resected margin of breast cancer contributes to increasing the local control rate in patients with close or positive margins in breast-conserving therapy (BCT). METHODS Among 837 patients with breast cancer who underwent BCT between November 1987 and December 1998, 181 patients with close or positive surgical margins received boost irradiation following conventional tangential whole breast irradiation. Since 1994, four radiopaque clips were surgically placed around the resected margin of the breast cancer in 155 patients treated with wide excision. The four clips were clearly and accurately identified with a CT-simulator (CT-S). The boost irradiation field was automatically determined with a safety margin of 3 cm according to one-to-one correspondence of radiopaque clips to pathologically close or positive surgical margins. In the remaining 26 patients treated before 1994, the boost irradiation field was determined according to the skin tattoo of the primary tumor. RESULTS The median follow-up period of the 155 patients receiving the radiopaque clips was 42 months (range: 19 to 78), and that of the 26 patients without the clips was 87 months. Local recurrence was observed in two of the 155 patients who underwent boost irradiation using the radiopaque clips 39 and 54 months after the surgery, while 4 of the 26 patients developed local recurrence 14, 23, 51, and 76 months after BCT. In three of the four patients without the clips developing local recurrences, local recurrences were observed at the margin of the boost irradiation field. The 5-year local recurrence-free survival rate of patients who received boost irradiation with the radiopaque clips was 97%, and that of patients without the clips was 88%. The difference of local recurrence-free survival rates between the patients with and without the clips was significant (p<0.05). CONCLUSION Surgically placed radiopaque clips appear to be useful for determining adequate boost field in the BCT using the CT-S and help increase the local control rate.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/mortality
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Contrast Media
- Disease-Free Survival
- Female
- Humans
- Japan
- Mastectomy, Segmental/methods
- Mastectomy, Segmental/mortality
- Middle Aged
- Radiotherapy, Adjuvant
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- M Kokubo
- Department of Therapeutic Radiology and Oncology, Graduate School of Medicine, Kyoto University, Japan
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34
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Bourez RL, Rutgers EJ. The European Organization for Research on Treatment of Cancer (eortc) Breast Cancer Group. Surg Oncol Clin N Am 2001. [DOI: 10.1016/s1055-3207(18)30033-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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35
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Deniaud-Alexandre E, Touboul E, Lefranc JP, Rolland J, Lin L, Julia LF, Keraudy K, Foulquier JN. [Breast-conserving surgery and irradiation for early breast cancer: value of surgical clips in the surgical cavity]. Cancer Radiother 2001; 5:255-61. [PMID: 11446079 DOI: 10.1016/s1278-3218(01)00100-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate, qualitatively and quantitatively, the role of surgical clips in planning the tumor bed electron or brachytherapy boost in patients undergoing breast-conserving surgery and radiotherapy. PATIENTS AND METHODS In 60 patients with breast cancer stage I or II, the excision cavity boundaries were marked by clips at surgery. Patients received a boost with brachytherapy (n = 51) or electron beam (n = 9) after whole breast irradiation. The boost target volume was first planned using clinical, mammography and operative information and its accuracy evaluated by screening the surgical clips and, if necessary, adjusting the field to encompass all clips and to include the scar. Dosimetry was retrospectively performed for each brachytherapy patient and for each surgical clip. RESULTS It was necessary to modify the target volume field in 11 cases (18%). The average dose received by the surgical clips was 116.1% of the dose delivered to the reference isodose (median: 101.75%, range: 16-457%). However, dose heterogeneity was important in the same patient and between patients. CONCLUSION Delineation of the boost target volume with surgical clips is more accurate than with clinical landmarks alone but this technique does not allow measurements of the clip-chest wall and clip-skin distances. Virtual simulation with CT-scan cuts is recommended for optimising boost planning.
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Affiliation(s)
- E Deniaud-Alexandre
- Service d'oncologie-radiothérapie, hôpital Tenon, 4, rue de la Chine, 75020 Paris, France
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Abstract
PURPOSE To compare computed tomography (CT) with ultrasonography (US) for depiction of the biopsy cavity. MATERIALS AND METHODS Thirty-two consecutive patients who underwent radiation therapy following lumpectomy with a planned electron boost were examined. At the time of simulation for whole-breast radiation therapy, all patients underwent planning CT (CT 1) at 3-mm section intervals. At the time of electron boost simulation, US was performed to define the biopsy cavity. In 17 cases, a second CT examination (CT 2) was performed at the time of electron boost simulation. CT and US studies were reviewed jointly and assigned a cavity visualization score (CVS) of 1 (cavity not visualized) to 5 (all cavity margins clearly defined). RESULTS The median CVS at CT 1 was 5; at CT 2, 4; and at US, 4. For patients who underwent all three studies, the median CVS at CT 1 was 5; at CT 2, 4; and at US, 4. Factors related to CVS at CT 1 were homogeneous versus heterogeneous appearance (score, 5 vs 4), surgery-to-CT interval (< or =30 days, 5; 31-60 days, 4; >60 days, 4), and cavity size (>15 cm(3), 5; <15 cm(3), 4). In all cases, cavity volume decreased somewhat during the CT 1-to-CT 2 interval. CONCLUSION CT performed at the time of whole-breast simulation can be used to plan electron boost fields, with cavity visualization similar to that at US.
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MESH Headings
- Adult
- Aged
- Biopsy
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Computer Simulation
- Female
- Humans
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Staging
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Adjuvant
- Tomography, X-Ray Computed
- Ultrasonography, Mammary
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Affiliation(s)
- M C Smitt
- Department of Radiation Oncology, Stanford Hospital, Stanford University Medical Center, 300 Pasteur Dr, Stanford, CA 94305, USA.
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Kovner F, Agay R, Merimsky O, Stadler J, Klausner J, Inbar M. Clips and scar as the guidelines for breast radiation boost after lumpectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1999; 25:483-6. [PMID: 10527596 DOI: 10.1053/ejso.1999.0683] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND AIMS Breast-conserving therapy in early breast cancer is equally effective as mastectomy, with advantages of cosmesis and quality of life over mastectomy. Local control is improved when entire breast irradiation is combined with a radiation boost to the tumour bed. METHODS Localization of the tumour bed was compared in 45 consecutive patients using surgical scar and radiopaque clips placed intra-operatively in the lumpectomy cavity. RESULTS The area (A) of the radiation boost field and volume (V) of the tumour bed, designed on the basis of scar (AS and VS), were 1.4 times larger than those designed on the basis of the clips (AC and VC). AS and VS missed about one-quarter of the tumour bed which had been delineated by clips intra-operatively, while about one-half of it encompassed tissues beyond the AC and VC. CONCLUSIONS A boost planned by scar dimensions can miss a substantial portion of the tumour bed, compromising local control. On the other hand, a substantial amount of breast tissue beyond the tumour bed can be unnecessarily irradiated, compromising cosmetic treatment results. Thus, the scar provides an inadequate landmark for radiation boost planning in breast-conserving therapy.
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Affiliation(s)
- F Kovner
- Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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Krawczyk JJ, Engel B. The importance of surgical clips for adequate tangential beam planning in breast conserving surgery and irradiation. Int J Radiat Oncol Biol Phys 1999; 43:347-50. [PMID: 10030260 DOI: 10.1016/s0360-3016(98)00402-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate the role of surgical clips in the planning of tangential beams in patients undergoing breast conserving surgery and adjuvant radiotherapy. METHODS AND MATERIALS Between September 1996 and April 1998, 25 consecutive female patients with ductal carcinoma in situ, Stage I and II cancer of the breast, underwent lumpectomy with the excision cavity marked by the surgical clips. Subsequently, tangential fields were planned using clinical and radiologic information obtained during simulation without the clips position being visible. RESULTS When measured from the center of the deepest clip to the posterior field border of the tangential fields in 6/25 patients (24%) the distance was less than 2 cm, with the closest being only 0.5 cm. Respective measurements for the distal end of the clip and the posterior border were: 9/25 patients (36%); less than 2 cm, with the closest distance of 0.3 cm. There was a positive correlation between the distance from the scar to the palpable breast border and the distance between the deepest clip and the posterior border of the tangential beams. CONCLUSION The lumpectomy scar is often a poor indicator of the excision cavity as demarcated by surgical clips. Without the clips, part of the cavity may be underdosed by the tangential radiation beams. This is more likely for the cavities located close to the lateral or medial border of the breast tissue.
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Affiliation(s)
- J J Krawczyk
- Department of Radiation Oncology, Allan Blair Cancer Centre, Regina, Saskatchewan, Canada
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Fortin A, Larochelle M, Laverdière J, Lavertu S, Tremblay D. Local failure is responsible for the decrease in survival for patients with breast cancer treated with conservative surgery and postoperative radiotherapy. J Clin Oncol 1999; 17:101-9. [PMID: 10458223 DOI: 10.1200/jco.1999.17.1.101] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE The aim of the present study was to evaluate the role of local failure (LF) in the survival of patients treated with lumpectomy and postoperative radiotherapy and to investigate whether LF is not only a marker for distant metastasis (DM) but also a cause. METHODS Charts of patients treated with breast conservative surgery between 1969 and 1991 were reviewed retrospectively. There were 2,030 patients available for analysis. The median duration of follow-up was 6 years. A Cox regression multivariate analysis was performed using LF as a time-dependent covariate. RESULTS Local control (LC) was 87% at 10 years. Local failure led to poorer survival at 10 years than local control (55% v 75%, P < .00). In a Cox model, local failure was a powerful predictor of mortality. The relative risk associated with LF was 3.6 for mortality and 5.1 for DM (P < .00). In patients with LF, the rate of DM peaked at 5 to 6 years, whereas it peaked at 2 years for patients with LC. The mean time between surgery and DM was 1,050 days for patients without LF and 1,650 days for patients with LF (P < .00). CONCLUSION Our results show that local failure is associated with an increase in mortality. The difference in the time distribution of distant metastasis for LF and LC could imply distinct mechanisms of dissemination. Local failure should be considered not only as a marker of occult circulating distant metastases but also as a source for new distant metastases and subsequent mortality.
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Affiliation(s)
- A Fortin
- Department of Radiation Oncology, Hôtel-Dieu de Québec Hospital, Université Laval, Canada
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Florell K, Halvorsen P. An accurate method for localization of the boost volume in breast radiotherapy. Med Dosim 1998; 22:283-91. [PMID: 9503371 DOI: 10.1016/s0958-3947(97)00101-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Patients with early stage breast cancer who are treated with adjuvant radiotherapy post-lumpectomy often receive a tumor bed boost with electrons. The tissue considered at high risk of local recurrence is defined from the surgical scar to the deepest portion of the tumor bed, which is ideally marked with radiopaque surgical clips. To adequately treat this tissue, one must superimpose the scar, surgical path and clips within the beam and choose an appropriate electron energy based on the deepest clip depth, while sparing low risk and cosmetically important tissues. Clip localization is therefore emphasized in the literature; however, published procedures do not adequately address how to meet all of the above goals. Additionally, CT planning alone cannot assess optimal coverage of tissue outside of the transverse plane, nor guarantee visualization of all clips. We have devised a method of boost planning based on localization of the surgical clips which may be accomplished in a single simulation session, utilizing two sets of orthogonal films, radiopaque skin surface markers, and FSD readings. Our procedure meets all of the above goals, is applicable to any field orientation that can be simulated, and can provide useful information for alternative techniques.
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Affiliation(s)
- K Florell
- FirstHealth Moore Regional Hospital, Department of Radiation Oncology, Pinehurst, NC 28374, USA
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Romestaing P, Mazeron JJ, Coquard R, Ardiet JM, Mornex F, Gérard JP. [Role of radiotherapy in the management of adenocarcinoma of the breast accessible to conservative surgery]. Cancer Radiother 1997; 1:14-28. [PMID: 9265530 DOI: 10.1016/s1278-3218(97)84053-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Standard treatment for limited stage adenocarcinoma of the breast includes lumpectomy (or a quadrantectomy), axillary node dissection, regional radiation therapy and, if the prognostic factors are unfavourable, chemotherapy and/or hormone therapy. This is supported by the results of American and European randomised trials. There have been many attempts at improving the modalities of conservative surgery and postoperative radiation therapy in order to maximize local control and minimize late sequellae. It is also likely that induction chemotherapy and external beam radiotherapy applied in selected cases increase the proportion of patients who can be offered conservative surgery.
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Affiliation(s)
- P Romestaing
- Service de radiothérapie-oncologie, centre hospitalier Lyon-Sud, Pierre, France
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Givens SS. Regarding Fein et al. IJROBP 34(5):1009-1017; 1996. Int J Radiat Oncol Biol Phys 1996; 36:525-6. [PMID: 8892483 DOI: 10.1016/s0360-3016(96)80190-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Fein DA, Fowble BL. In response to Dr. Givens. Int J Radiat Oncol Biol Phys 1996. [DOI: 10.1016/s0360-3016(96)90027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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In response to Dr. Richards. Int J Radiat Oncol Biol Phys 1996. [DOI: 10.1016/s0360-3016(96)90065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Morrow M. Improving local control in breast conserving therapy: to clip or not to clip? Int J Radiat Oncol Biol Phys 1996; 34:1173-4. [PMID: 8600103 DOI: 10.1016/0360-3016(96)00068-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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