Comparison of three concomitant boost techniques for early-stage breast cancer

Sequential or simultaneous-integrated boost in early-stage breast cancer patients: trade-offs between skin toxicity and risk of compromised coverage

PURPOSE

To determine the dosimetric effects of set-up errors on boost coverage, and compares skin toxicity of sequential and simultaneous boost techniques for left-sided breast cancer.

MATERIALS AND METHODS

This retrospective study included 23 early-stage breast cancer cases. Single isocenter HFWBI-SIB(s-SIB), single isocenter HFWBI-SB(s-SB) and dual isocenter HFWBI-SB(d-SB) were planing. Rotations of 0.5°, 1°, and 2° coupled with translationals of 0.5 mm, 1.0 mm, and 2.0 mm were applied along three orthogonal axes. The dose to 95% of the PTV (D95) and the volume covered by 95% of the prescribed dose (V95) were evaluated using GEE univariate analysis to determine how PTV coverage was related to 1/CIRTOG, PTVboost volume, PTVboost separation to isocenter. The relationship between the high-dose regions within the PTVbreast and Ratio_V was evaluated using univariate analysis.

RESULTS

The s-SIB had optimal target coverage and lower high-dose volume, but it increased the risk of compromised coverage to tumor bed. For the s-SB technique, V95 exceeded 95% under all setup errors. At 2.0° coupled with 2.0 mm, s-SIB and d-SB exhibited V95 values below 95% in 34.8% and 8.7% of cases, respectively. At other setup errors, both s-SIB and d-SB demonstrated V95 values greater than 95%. Notably, high-dose regions such as V105%, V107%, and V110% within the PTVbreast across the three techniques displayed a significant correlation with Ratio_V.

CONCLUSION

Simultaneous-integrated boost for early-stage breast cancer can reduce skin toxicity compared to sequential techniques but with the risk of compromising tumor bed coverage.

Optimization of the Dose-Volume Effect Parameter "a" in EUD-Based TCP Models for Breast Cancer Radiotherapy

IntroductionRadiotherapy treatment plans traditionally rely on physical indices like Dose-volume histograms and spatial dose distributions. While these metrics assess dose delivery, they lack consideration for the biological effects on tumors and healthy tissues. To address this, radiobiological models like tumor control probability (TCP) and Normal tissue complications probability (NTCP) are increasingly incorporated to evaluate treatment efficacy and potential complications. This study aimed to assess the predictive power of radiobiological models for TCP in breast cancer radiotherapy and provide insights into the model selection and parameter optimization.MethodsIn this retrospective observational study, two commonly used models, the Linear-Poisson and Equivalent uniform dose (EUD)-based models, were employed to calculate TCP for 30 patients. Different radiobiological parameter sets were investigated, including established sets from literature (G1 and G2) and set with an optimized "a" parameter derived from clinical trial data (a1 and a2). Model predictions were compared with clinical outcomes from the START trials.ResultsThe Linear-Poisson model with es lished parameter sets from the literature demonstrated good agreement with clinical data. The standard EUD-based model (a = -7.2) significantly underestimated TCP. While both models exhibited some level of independence from the specific parameter sets (G1 vs. G2), the EUD-based model was susceptible to the "a" parameter value. Optimization suggests a more accurate "a" value closer to -2.57 and -5.65.ConclusionThis study emphasizes the importance of clinically relevant radiobiological parameters for accurate TCP prediction and optimizing the "a" parameter in the EUD-based model based on clinical data (a1 and a2) improved its predictive accuracy significantly.

Quantify the Effect of Air Gap Errors on Skin Dose for Breast Cancer Radiotherapy

Purpose: Determining the impact of air gap errors on the skin dose in postoperative breast cancer radiotherapy under dynamic intensity-modulated radiation therapy (IMRT) techniques. Methods: This was a retrospective study that involved 55 patients who underwent postoperative radiotherapy following modified radical mastectomy. All plans employed tangential IMRT, with a prescription dose of 50 Gy, and bolus added solely to the chest wall. Simulated air gap depth errors of 2 mm, 3 mm, and 5 mm were introduced at depression or inframammary fold areas on the skin, resulting in the creation of air gaps named Air2, Air3, and Air5. Utilizing a multivariable GEE, the average dose (Dmean) of the local skin was determined to evaluate its relationship with air gap volume and the lateral beam's average angle (AALB). Additionally, an analysis was conducted on the impact of gaps on local skin. Results: When simulating an air gap depth error of 2 mm, the average Dmean in plan2 increased by 0.46 Gy compared to the initial plan (planO) (p < .001). For the 3-mm air gap, the average Dmean of plan3 was 0.51 Gy higher than that of planO (p < .001). When simulating the air gap as 5 mm, the average Dmean of plan5 significantly increased by 0.59 Gy compared to planO (p < .001). The TCP results showed a similar trend to those of Dmean. As the depth of air gap error increases, NTCP values also gradually rise. The linear regression of the multivariable GEE equation indicates that the volume of air gaps and the AALB are strong predictors of Dmean. Conclusion: With small irregular air gap errors simulated in 55 patients, the values of skin's Dmean, TCP, and NTCP increased. A multivariable linear GEE regression model may effectively explain the impact of air gap volume and AALB on the local skin.

Dosimetric and radiobiological comparison between conventional and hypofractionated breast treatment plans using the Halcyon system

Purpose

The objective of this research is to compare the efficacy of conventional and hypofractionated radiotherapy treatment plans for breast cancer patients, with a specific focus on the unique features of the Halcyon system.

Methods and materials

The study collected and analyzed dose volume histogram (DVH) data for two groups of treatment plans implemented using the Halcyon system. The first group consisted of 19 patients who received conventional fractionated (CF) treatment with a total dose of 50 Gy in 25 fractions, while the second group comprised 9 patients who received hypofractionated (HF) treatment with a total dose of 42.56 Gy in 16 fractions. The DVH data was used to calculate various parameters, including tumor control probability (TCP), normal tissue complication probability (NTCP), and equivalent uniform dose (EUD), using radiobiological models.

Results

The results indicated that the CF plan resulted in higher TCP but lower NTCP for the lungs compared to the HF plan. The EUD for the HF plan was approximately 49 Gy (114% of its total dose) while that for the CF plan was around 53 Gy (107% of its total dose).

Conclusions

The analysis suggests that while the CF plan is better at controlling tumors, it is not as effective as the HF plan in minimizing side effects. Additionally, it is suggested that there may be an optimal configuration for the HF plan that can provide the same or higher EUD than the CF plan.

Comparison of photon versus electron for tumor bed boost radiotherapy post-breast conserving surgery

INTRODUCTION

The standard treatment (photon or electron) for tumor bed boost in breast cancer has not yet been clearly established. The aim of this work was to compare photon vs. electron for tumor bed boost radiotherapy post breast-conserving surgery and whole-breast irradiation concerning different dosimetric parameters.

METHODS

This study included 51 patients who underwent conservative surgery and adjuvant radiotherapy. Of these, 28 patients had right-sided and 23 patients had a left-sided tumors. All patients in this study were treated with photon and then re-planned with electron plans.

RESULTS

Both techniques electron and photon plans provided acceptable results while there was a better performance of the latter in terms of target coverage with statistical significance (p < 0.05). The global and maximum dose was significantly higher with electron compared to photon. Homogeneity index (HI) and conformity index (CI) and conformity number (CN) were better in photon plans, especially in deep-seated tumors. The quality of electron plans differed between patients according to depth, irregular shapes, and location of the tumor bed boost. The results of organs at risk (OARs) for ipsilateral lung and heart showed that photon plans were better than electron plans (p < 0.05), especially at a low dose (V2Gy and V1Gy) for ipsilateral lung. For contralateral breast, both photon and electron had nearly comparable results, where the dose delivered to the contralateral breast for both techniques was close to zero. Interestingly, the number of monitor units (MU) was reduced in electron compared to photon by 15.94% (p < 0.001).

CONCLUSIONS

This study recommends the use of photon in treatment of tumor bed boost in conservative breast cancer and then electron as a second line when the former is not available.

Breast boost vector: a new metric proposed to optimise isocentre location in an fIMRT–VMAT hybrid technique for a simultaneous integrated boost in breast radiotherapy

Purpose:

Evaluating the improvements of placing the treatment isocentre at the boost centre of mass (CoM) in a hybrid treatment for breast cancer radiotherapy.

Material and methods:

Twenty-two patients were planned in two isocentre locations with two forward intensity-modulated radiation therapy (fIMRT) tangentials to the breast and a volumetric-modulated arc therapy (VMAT) to the boost. A simultaneous integrated boost technique was used. Breast Boost (BB) Vector was investigated as a criterion for selecting an appropriate isocentre placement. Various metrics for boost, breast and hybrid plans were analysed using analysis of variance statistics.

Results:

Comparing hybrid plans at the boost CoM vs. hybrid plans at the breast CoM, no significant differences were found. Analysis of relative variations of planning target volume (PTV) boost coverage vs. BB Vector indicated an upgrade in boost CoM isocentre strategy. Dose to organs at risk was comparable: V5Gy (26·24 vs. 25·69%, p = 0·8), V20Gy (14·66 vs. 14·58%, p = 0·959) and the mean dose (7·37 Gy vs. 7·26 Gy, p = 0·879) to ipsilateral lung; V5Gy (15·60 vs. 15·22%, p = 0·903), and the mean dose (4·91 Gy vs. 4·86 Gy, p = 0·950) to heart and dose to free breast of boost (46·71 Gy vs. 46·62 Gy, p = 0·408).

Findings:

The hybrid fIMRT–VMAT technique centred at the boost CoM resulted equivalent to plans centred at the breast CoM, while benefiting from an enhancement in PTV boost coverage for patients with BB Vector superior to 5.

Radiobiological and dosimetric impact of RayStation pencil beam and Monte Carlo algorithms on intensity-modulated proton therapy breast cancer plans

PURPOSE

RayStation treatment planning system employs pencil beam (PB) and Monte Carlo (MC) algorithms for proton dose calculations. The purpose of this study is to evaluate the radiobiological and dosimetric impact of RayStation PB and MC algorithms on the intensity-modulated proton therapy (IMPT) breast plans.

METHODS

The current study included ten breast cancer patients, and each patient was treated with 1-2 proton beams to the whole breast/chestwall (CW) and regional lymph nodes in 28 fractions for a total dose of 50.4 Gy relative biological effectiveness (RBE). A total clinical target volume (CTV_Total) was generated by combining individual CTVs: AxI, AxII, AxIII, CW, IMN, and SCVN. All beams in the study were treated with a range shifter (7.5 cm water equivalent thickness). For each patient, three sets of plans were generated: (a) PB optimization followed by PB dose calculation (PB-PB), (b) PB optimization followed by MC dose calculation (PB-MC), and (c) MC optimization followed by MC dose calculation (MC-MC). For a given patient, each plan was robustly optimized on the CTVs with same parameters and objectives. Treatment plans were evaluated using dosimetric and radiobiological indices (equivalent uniform dose (EUD), tumor control probability (TCP), and normal tissue complication probability (NTCP)).

RESULTS

The results are averaged over ten breast cancer patients. In comparison to PB-PB plans, PB-MC plans showed a reduction in CTV target dose by 5.3% for D_99% and 4.1% for D_95% , as well as a reduction in TCP by 1.5-2.1%. Similarly, PB overestimated the EUD of target volumes by 1.8─3.2 Gy(RBE). In contrast, MC-MC plans achieved similar dosimetric and radiobiological (EUD and TCP) results as the ones in PB-PB plans. A selection of one dose calculation algorithm over another did not produce any noticeable differences in the NTCP of the heart, lung, and skin.

CONCLUSION

If MC is more accurate than PB as reported in the literature, dosimetric and radiobiological results from the current study suggest that PB overestimates the target dose, EUD, and TCP for IMPT breast cancer treatment. The overestimation of dosimetric and radiobiological results of the target volume by PB needs to be further interpreted in terms of clinical outcome.

Comparison of gamma index based on dosimetric error and clinically relevant dose-volume index based on three-dimensional dose prediction in breast intensity-modulated radiation therapy

Background

Measurement-guided dose reconstruction has lately attracted significant attention because it can predict the delivered patient dose distribution. Although the treatment planning system (TPS) uses sophisticated algorithm to calculate the dose distribution, the calculation accuracy depends on the particular TPS used. This study aimed to investigate the relationship between the gamma passing rate (GPR) and the clinically relevant dose–volume index based on the predicted 3D patient dose distribution derived from two TPSs (XiO, RayStation).

Methods

Twenty-one breast intensity-modulated radiation therapy plans were inversely optimized using XiO. With the same plans, both TPSs calculated the planned dose distribution. We conducted per-beam measurements on the coronal plane using a 2D array detector and analyzed the difference in 2D GPRs between the measured and planned doses by commercial software. Using in-house software, we calculated the predicted 3D patient dose distribution and derived the predicted 3D GPR, the predicted per-organ 3D GPR, and the predicted clinically relevant dose–volume indices [dose–volume histogram metrics and the value of the tumor-control probability/normal tissue complication probability of the planning target volume and organs at risk]. The results derived from XiO were compared with those from RayStation.

Results

While the mean 2D GPRs derived from both TPSs were 98.1% (XiO) and 100% (RayStation), the mean predicted 3D GPRs of ipsilateral lung (73.3% [XiO] and 85.9% [RayStation]; p < 0.001) had no correlation with 2D GPRs under the 3% global/3 mm criterion. Besides, this significant difference in terms of referenced TPS between XiO and RayStation could be explained by the fact that the error of predicted V_5Gy of ipsilateral lung derived from XiO (29.6%) was significantly larger than that derived from RayStation (− 0.2%; p < 0.001).

Conclusions

GPR is useful as a patient quality assurance to detect dosimetric errors; however, it does not necessarily contain detailed information on errors. Using the predicted clinically relevant dose–volume indices, the clinical interpretation of dosimetric errors can be obtained. We conclude that a clinically relevant dose–volume index based on the predicted 3D patient dose distribution could add to the clinical and biological considerations in the GPR, if we can guarantee the dose calculation accuracy of referenced TPS.

Evaluation of the radiobiological gamma index with motion interplay in tangential IMRT breast treatment

The purpose of this study was to evaluate the impact of the motion interplay effect in early-stage left-sided breast cancer intensity-modulated radiation therapy (IMRT), incorporating the radiobiological gamma index (RGI). The IMRT dosimetry for various breathing amplitudes and cycles was investigated in 10 patients. The predicted dose was calculated using the convolution of segmented measured doses. The physical gamma index (PGI) of the planning target volume (PTV) and the organs at risk (OAR) was calculated by comparing the original with the predicted dose distributions. The RGI was calculated from the PGI using the tumor control probability (TCP) and the normal tissue complication probability (NTCP). The predicted mean dose and the generalized equivalent uniform dose (gEUD) to the target with various breathing amplitudes were lower than the original dose (P < 0.01). The predicted mean dose and gEUD to the OARs with motion were higher than for the original dose to the OARs (P < 0.01). However, the predicted data did not differ significantly between the various breathing cycles for either the PTV or the OARs. The mean RGI gamma passing rate for the PTV was higher than that for the PGI (P < 0.01), and for OARs, the RGI values were higher than those for the PGI (P < 0.01). The gamma passing rates of the RGI for the target and the OARs other than the contralateral lung differed significantly from those of the PGI under organ motion. Provided an NTCP value <0.05 is considered acceptable, it may be possible, by taking breathing motion into consideration, to escalate the dose to achieve the PTV coverage without compromising the TCP.

Intensity modulated radiation therapy with simultaneous integrated boost in early breast cancer irradiation. Report of feasibility and preliminary toxicity

PURPOSE

To investigate the feasibility and tolerance in the use of adjuvant intensity modulated radiation therapy (IMRT) and simultaneous integrated boost in patients with a diagnosis of breast cancer after breast-conserving surgery.

PATIENTS AND METHODS

Between September 2011 to February 2013, 112 women with a diagnosis of early breast cancer (T1-2, N0-1, M0) were treated with IMRT and simultaneous integrated boost after breast-conserving surgery in our institution. A dose of 50Gy in 25 fractions was prescribed to the whole breast and an additional dose of radiation was prescribed on the tumour bed. A dose prescription of 60Gy in 25 fractions to the tumour bed was used in patients with negative margins after surgery, whereas if the margins were close (<1mm) or positive (without a new surgical resection) a dose of 64Gy was prescribed. All patients were followed with periodic clinical evaluation. Acute and late toxicity were scored using the EORTC/RTOG radiation morbidity score system. Both patient and physician recorded cosmetic outcome evaluation with a subjective judgment scale at the time of scheduled follow-up.

RESULTS

The median follow-up was 28 months (range 24-40 months). The acute skin grade toxicity during the treatment was grade 0 in 8 patients (7%), grade 1 in 80 (72%), grade 2 in 24 cases (21%). No grade 3 or higher acute skin toxicity was observed. At 12 months, skin toxicity was grade 0 in 78 patients (70%), grade 1 in 34 patients (30%). No toxicity grade 2 or higher was registered. At 24 months, skin toxicity was grade 0 in 79 patients (71%), grade 1 in 33 patients (29%). No case of grade 2 toxicity or higher was registered. The pretreatment variables correlated with skin grade 2 acute toxicity were adjuvant chemotherapy (P=0.01) and breast volume ≥700cm(3) (P=0.001). Patients with an acute skin toxicity grade 2 had a higher probability to develop late skin toxicity (P<0.0001). In the 98% of cases, patients were judged to have a good or excellent cosmetic outcome. The 2-year-overall survival and 2-year-local control were 100%.

CONCLUSION

These data support the feasibility and safety of IMRT with simultaneous integrated boost in patients with a diagnosis of early breast cancer following breast-conserving surgery with acceptable acute and late treatment-related toxicity. A longer follow-up is needed to define the efficacy on outcomes.

Comparison of electron and x-ray beams for tumor bed boost irradiation in breast-conserving treatment

Purpose

This study aimed to compare the dosimetric profiles of electron beams (EB) and X-ray beams (XB) for boosting irradiation in breast cancer patients who underwent breast-conserving surgery and postoperative radiotherapy.

Methods

For 131 breast cancer patients who underwent breast-conserving surgery, we compared plans for EB and XB boost irradiation after whole-breast irradiation. The organs at risk (OAR) included the cardiac chambers, coronary arteries, ipsilateral lung, and skin. The conformity index (CI), inhomogeneity index (IHI), and dose-volume parameters for the planning target volume (PTV), and OAR were calculated. Postradiotherapy chest computed tomography scans were performed to detect radiation pneumonitis.

Results

XB plans showed a significantly better CI and IHI for the PTVs, compared to the EB plans. Regarding OAR sparing, the XB reduced the high-dose volume at the expense of an increased low-dose volume. In 33 patients whose radiation fields included nipples, IHI was higher in the EB plans, whereas the presence of a nipple in the radiation field did not interfere with the XB. EB-treated patients developed more subclinical radiation pneumonitis.

Conclusion

XB plans were superior to EB plans in terms of PTV coverage (homogeneity and conformity) and high-dose volume sparing in OAR when used as boost irradiation after breast-conserving surgery. A disadvantage of the XB plan was an increased low-dose volume in the OAR, but this was offset by the increased electron energy. Consequently, tailored plans with either XB or EB are necessary to adapt to patient anatomic variance and tumor bed geometric properties.

Whole breast and excision cavity radiotherapy plan comparison: Conformal radiotherapy with sequential boost versus intensity-modulated radiation therapy with a simultaneously integrated boost

Introduction

A comparative study was conducted comparing the difference between (1) conformal radiotherapy (CRT) to the whole breast with sequential boost excision cavity plans and (2) intensity-modulated radiation therapy (IMRT) to the whole breast with simultaneously integrated boost to the excision cavity. The computed tomography (CT) data sets of 25 breast cancer patients were used and the results analysed to determine if either planning method produced superior plans.

Methods

CT data sets from 25 past breast cancer patients were planned using (1) CRT prescribed to 50 Gy in 25 fractions (Fx) to the whole-breast planning target volume (PTV) and 10 Gy in 5Fx to the excision cavity and (2) IMRT prescribed to 60 Gy in 25Fx, with 60 Gy delivered to the excision cavity PTV and 50 Gy delivered to the whole-breast PTV, treated simultaneously. In total, 50 plans were created, with each plan evaluated by PTV coverage using conformity indices, plan maximum dose, lung dose, and heart maximum dose for patients with left-side lesions.

Results

CRT plans delivered the lowest plan maximum doses in 56% of cases (average CRT = 6314.34 cGy, IMRT = 6371.52 cGy). They also delivered the lowest mean lung dose in 68% of cases (average CRT = 1206.64 cGy, IMRT = 1288.37 cGy) and V20 in 88% of cases (average CRT = 20.03%, IMRT = 21.73%) and V30 doses in 92% of cases (average CRT = 16.82%, IMRT = 17.97%). IMRT created more conformal plans, using both conformity index and conformation number, in every instance, and lower heart maximum doses in 78.6% of cases (average CRT = 5295.26 cGy, IMRT = 5209.87 cGy).

Conclusion

IMRT plans produced superior dose conformity and shorter treatment duration, but a slightly higher planning maximum and increased lung doses. IMRT plans are also faster to treat on a daily basis, with shorter fractionation.

Dosimetric evaluation of breast radiotherapy in a dynamic phantom

This phantom study quantifies changes in delivered dose due to respiratory motion for four breast radiotherapy planning techniques: three intensity-modulated techniques (forward-planned, surface-compensated and hybrid intensity-modulated radiation therapy (IMRT)); using a combination of open fields and inverse planned IMRT) and a 2D conventional technique. The plans were created on CT images of a wax breast phantom with a cork lung insert, and dose distributions were measured using films inserted through slits in the axial and sagittal planes. Films were irradiated according to each plan under a static (modeling breathhold) and three dynamic conditions--isocenter set at mid-respiratory cycle with motion amplitudes of 1 and 2 cm and at end-cycle with 2 cm motion amplitude (modeling end-exhale). Differences between static and moving deliveries were most pronounced for the more complex planning techniques with hot spots of up to 107% appearing in the anterior portion of all three IMRT plans at the largest motion at the end-exhale set-up. The delivered dose to the moving phantom was within 5% of that to the static phantom for all cases, while measurement accuracy was ±3%. The homogeneity index was significantly decreased only for the 2 cm motion end-exhale set-up; however, this same motion increased the equivalent uniform dose because of improved posterior breast coverage. Overall, the study demonstrates that the effect of respiratory motion is negligible for all planning techniques except in occasional instances of large motion.

Comparison between intensity modulated radiotherapy (IMRT) and 3D tangential beams technique used in patients with early-stage breast cancer who received breast-conserving therapy

BACKGROUND

The most often found complications in patients with breast cancer who received radiotherapy are cardiac and pulmonary function disorders and development of second malignancies.

AIM

To compare the intensity modulated radiotherapy with the 3D tangential beams technique in respect of dose distribution in target volume and critical organs they generate in patients with early-stage breast cancer who received breast-conserving therapy.

MATERIALS AND METHODS

A dosimetric analysis was performed to assess the three radiotherapy techniques used in each of 10 consecutive patients with early-stage breast cancer treated with breast-conserving therapy. Radiotherapy was planned with the use of all the three techniques: 3D tangential beams with electron boost, IMRT with electron boost, and intensity modulated radiotherapy with simultaneous integrated boost.

RESULTS

The use of the IMRT techniques enables more homogenous dose distribution in target volume. The range of mean and median dose to the heart and lung was lower with the IMRT techniques in comparison to the 3D tangential beams technique. The range of mean dose to the heart amounted to 0.3-3.5 Gy for the IMRT techniques and 0.4-4.3 for the tangential beams technique. The median dose to the lung on the irradiated side amounted to 4.9-5 Gy for the IMRT techniques and 5.6 Gy for the 3D tangential beams technique.

CONCLUSION

The application of the IMRT techniques in radiotherapy patients with early-stage breast cancer allows to obtain more homogenous dose distribution in target volume, while permitting to reduce the dose to critical organs.

Phase I-II studies on accelerated IMRT in breast carcinoma: technical comparison and acute toxicity in 332 patients

BACKGROUND AND PURPOSE

To evaluate the results in terms of dosimetric parameters and acute toxicity of two clinical studies (MARA-1 and MARA-2) on accelerated IMRT-based postoperative radiotherapy. These results are compared with historical control group (CG) of patients treated with "standard" 3D postoperative radiotherapy.

MATERIALS AND METHODS

Prescribed dose to the breast was 50.4Gy in the CG, 40Gy in MARA-1 (low risk of local recurrence), and 50Gy in MARA-2 (medium-high risk of recurrence). The tumor bed total dose was 60.4Gy (sequential 10Gy electron boost), 44Gy (concomitant 4Gy boost), and 60Gy (concomitant 10Gy boost) in CG, MARA-1 and MARA-2 studies, respectively. Overall treatment time was of 32 fractions for CG (6.4weeks); 16 fractions for MARA-1 study (3.2weeks) and 25 fractions for MARA-2 study (5weeks).

RESULTS

Three hundred and thirty two patients were included in the analysis. Dosimetric analysis showed D(max) and V(107%) reduction (p<0.001) and D(min) improvement (p<0.001) in the PTV in patients treated with IMRT. Grade 2 acute skin toxicity was 33.6%, 13.1%, and 45.1% in the CG, MARA-1, and MARA-2, respectively (p<0.001), and grade 3 acute skin toxicity was 3.1%, 1.0%, and 2.0%, respectively. Similarly, larger PTV and use of chemotherapy with anthracyclines and taxanes were associated with a greater acute toxicity. With a median follow-up of 31 months, no patients showed local or nodal relapse.

CONCLUSIONS

A simplified step and shoot IMRT technique allowed better PTV coverage and reduced overall treatment time (CG, 6.6weeks; MARA-1, 3.2weeks; MARA-2, 5weeks) with acceptable short-term toxicity.

Techniques of tumour bed boost irradiation in breast conserving therapy: current evidence and suggested guidelines

Breast conservation surgery followed by external beam radiotherapy to breast has become the standard of care in management of early carcinoma breast. A boost to the tumour bed after whole breast radiotherapy is employed in view of the pattern of tumour bed recurrences in the index quadrant and was particularly considered in patients with some adverse histopathological characteristics such as positive margins, extensive intraductal carcinoma (EIC), lymphovascular invasion dose in patients even without such factors and for all age groups. The maximum absolute reduction of local recurrences by the addition of boost is especially seen in young premenopausal patients. At the same time, the addition of boost is associated with increased risk of worsening of cosmesis and no clear cut survival advantage. Radiological modalities such as fluoroscopy, ultrasound and CT scan have aided in accurate delineation of tumour bed with increasing efficacy. A widespread application of these techniques might ultimately translate into improved local control with minimal cosmetic deficit. The present article discusses the role of radiotherapy boost and the means to delineate and deliver the same, identify the high risk group, optimal technique and the doses and fractionations to be used. It also discusses the extent of adverse cosmetic outcome after boost delivery, means to minimise it and relevance of tumour bed in present day scenario of advanced radiotherapy delivery techniques like Intensity modulated radiation therapy (IMRT).

Role of 10-Gy boost radiation after breast-conserving surgery for stage I–II breast cancer with a 5-mm negative margin

BACKGROUND

According to the Guidelines for breast-conserving therapy of the Japanese Breast Cancer Society, the surgical margin is "negative" when the minimum distance between the tumor edge and the margin of the resected specimen is more than 5 mm. The value of boost radiation for early breast cancer with a 5-mm negative margin remains unclear.

METHODS

A total of 137 patients with stage I-II breast cancer underwent breast-conserving surgery between July 1987 and August 2002. All of the patients had negative margins according to the Japanese guidelines. Their median age was 50 years and the median follow-up period was 62 months. The entire ipsilateral breast was irradiated to a total dose of 50 Gy (25 fractions). Then an additional 10 Gy (5 fractions) was given to 79 patients, using 6- to 12-MeV electrons (boost group), while 58 patients (no-boost group) received no further radiation. Factors influencing local recurrence were evaluated by univariate and multivariate analyses.

RESULTS

For the entire population, the 5-year overall survival, cause-specific survival, disease-free survival, and local recurrence rates were 96.0%, 96.8%, 94.2%, and 1.67%, respectively. Boost radiation reduced local recurrence, but the improvement was not significant (P = 0.070). Univariate and multivariate analyses failed to detect any factors that were significantly associated with local control. There were no severe complications in either group and there were no differences between the groups in the cosmetic outcome.

CONCLUSION

Boost radiation can be performed for stage I-II breast cancer with negative margins (Japanese guidelines), and showed a tendency to decrease local recurrence. A large randomized controlled study is necessary to establish final conclusions.

The Equivalent Uniform Dose as a severity metric for radiation treatment incidents

In allocating resources within a risk management program, ideally we would like to know both the probabilities and consequences of potential incidents. We simulate, on a treatment planning computer, several commonly reported incidents in radiation treatment and explore their consequences for the EUDs of targets and organs at risk.

Phase I-II Trial of Prone Accelerated Intensity Modulated Radiation Therapy to the Breast to Optimally Spare Normal Tissue

Purpose

To report the clinical feasibility of a trial of accelerated whole-breast intensity modulated radiotherapy, with the patient in prone position, optimally to spare the heart and lung.

Patients and Methods

Patients with stages I or II breast cancer, excised by breast conserving surgery with negative margins, were eligible for this institutional review board–approved prospective trial. Computed tomography simulation was performed with the patient prone on a dedicated breast board, in the exact position used for treatment. A dose of 40.5 Gy, delivered at 2.7 Gy in 15 fractions, was prescribed to the index breast with an additional concomitant boost of 0.5 Gy delivered to the tumor bed, for a total dose of 48 Gy to the lumpectomy site. Physics constraints consisted of limiting ≤ 5% of the heart volume to receive ≥ 18 Gy and ≤ 10% of the ipsilateral lung volume to receive ≥ 20 Gy.

Results

Between September 2003 and August 2005, 91 patients were enrolled on the study. Median length of follow-up was 12 months (range, 1 to 28 months). In all patients the technique was feasible and heart and lung sparing was achieved as prescribed by the protocol. Acute toxicities consisting mostly of reversible grades 1-2 skin dermatitis (67%) and fatigue (18%) occurred in 75 patients. One patient sustained a regional recurrence rapidly followed by distant metastases.

Conclusion

Accelerated whole breast intensity modulated radiotherapy in the prone position is feasible and it permits a drastic reduction in the volume of lung and heart tissue exposed to significant radiation.

High-dose simultaneously integrated breast boost using intensity-modulated radiotherapy and inverse optimization

PURPOSE

Recently a Phase III randomized trial has started comparing a boost of 16 Gy as part of whole-breast irradiation to a high boost of 26 Gy in young women. Our main aim was to develop an efficient simultaneously integrated boost (SIB) technique for the high-dose arm of the trial.

METHODS AND MATERIALS

Treatment planning was performed for 5 left-sided and 5 right-sided tumors. A tangential field intensity-modulated radiotherapy technique added to a sequentially planned 3-field boost (SEQ) was compared with a simultaneously planned technique (SIB) using inverse optimization. Normalized total dose (NTD)-corrected dose volume histogram parameters were calculated and compared.

RESULTS

The intended NTD was produced by 31 fractions of 1.66 Gy to the whole breast and 2.38 Gy to the boost volume. The average volume of the PTV-breast and PTV-boost receiving more than 95% of the prescribed dose was 97% or more for both techniques. Also, the mean lung dose and mean heart dose did not differ much between the techniques, with on average 3.5 Gy and 2.6 Gy for the SEQ and 3.8 Gy and 2.6 Gy for the SIB, respectively. However, the SIB resulted in a significantly more conformal irradiation of the PTV-boost. The volume of the PTV-breast, excluding the PTV-boost, receiving a dose higher than 95% of the boost dose could be reduced considerably using the SIB as compared with the SEQ from 129 cc (range, 48-262 cc) to 58 cc (range, 30-102 cc).

CONCLUSIONS

A high-dose simultaneously integrated breast boost technique has been developed. The unwanted excessive dose to the breast was significantly reduced.

A theoretical approach to the problem of dose-volume constraint estimation and their impact on the dose-volume histogram selection

This paper outlines a theoretical approach to the problem of estimating and choosing dose-volume constraints. Following this approach, a method of choosing dose-volume constraints based on biological criteria is proposed. This method is called "reverse normal tissue complication probability (NTCP) mapping into dose-volume space" and may be used as a general guidance to the problem of dose-volume constraint estimation. Dose-volume histograms (DVHs) are randomly simulated, and those resulting in clinically acceptable levels of complication, such as NTCP of 5 +/- 0.5%, are selected and averaged producing a mean DVH that is proven to result in the same level of NTCP. The points from the averaged DVH are proposed to serve as physical dose-volume constraints. The population-based critical volume and Lyman NTCP models with parameter sets taken from literature sources were used for the NTCP estimation. The impact of the prescribed value of the maximum dose to the organ, D(max), on the averaged DVH and the dose-volume constraint points is investigated. Constraint points for 16 organs are calculated. The impact of the number of constraints to be fulfilled based on the likelihood that a DVH satisfying them will result in an acceptable NTCP is also investigated. It is theoretically proven that the radiation treatment optimization based on physical objective functions can sufficiently well restrict the dose to the organs at risk, resulting in sufficiently low NTCP values through the employment of several appropriate dose-volume constraints. At the same time, the pure physical approach to optimization is self-restrictive due to the preassignment of acceptable NTCP levels thus excluding possible better solutions to the problem.