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De-Colle C, Kirby A, Russell N, Shaitelman S, Currey A, Donovan E, Hahn E, Han K, Anandadas C, Mahmood F, Lorenzen E, van den Bongard D, Groot Koerkamp M, Houweling A, Nachbar M, Thorwarth D, Zips D. Adaptive radiotherapy for breast cancer. Clin Transl Radiat Oncol 2023; 39:100564. [PMID: 36632056 PMCID: PMC9826896 DOI: 10.1016/j.ctro.2022.100564] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Research in the field of local and locoregional breast cancer radiotherapy aims to maintain excellent oncological outcomes while reducing treatment-related toxicity. Adaptive radiotherapy (ART) considers variations in target and organs at risk (OARs) anatomy occurring during the treatment course and integrates these in re-optimized treatment plans. Exploiting ART routinely in clinic may result in smaller target volumes and better OAR sparing, which may lead to reduction of acute as well as late toxicities. In this review MR-guided and CT-guided ART for breast cancer patients according to different clinical scenarios (neoadjuvant and adjuvant partial breast irradiation, whole breast, chest wall and regional nodal irradiation) are reviewed and their advantages as well as challenging aspects discussed.
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Affiliation(s)
- C. De-Colle
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - A. Kirby
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, United Kingdom
| | - N. Russell
- Department of Radiotherapy, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - S.F. Shaitelman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - A. Currey
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - E. Donovan
- Department of Radiation Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Canada
| | - E. Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - K. Han
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada
| | - C.N. Anandadas
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - F. Mahmood
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - E.L. Lorenzen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | - M.L. Groot Koerkamp
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - A.C. Houweling
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands
| | - M. Nachbar
- Section for Biomedical Physics, Department of Radiation Oncology. University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
| | - D. Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology. University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - D. Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty, Eberhard Karls University Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), partner site Tübingen; and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Sager O, Dincoglan F, Demiral S, Uysal B, Gamsiz H, Ozcan F, Colak O, Elcim Y, Gundem E, Dirican B, Beyzadeoglu M. Adaptive radiation therapy of breast cancer by repeated imaging during irradiation. World J Radiol 2020; 12:68-75. [PMID: 32549955 PMCID: PMC7288774 DOI: 10.4329/wjr.v12.i5.68] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/08/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023] Open
Abstract
Breast cancer is the most frequent cancer among females and also a leading cause of cancer related mortality worldwide. A multimodality treatment approach may be utilized for optimal management of patients with combinations of surgery, radiation therapy (RT) and systemic treatment. RT composes an integral part of breast conserving treatment, and is typically used after breast conserving surgery to improve local control. Recent years have witnessed significant improvements in the discipline of radiation oncology which allow for more focused and precise treatment delivery. Adaptive radiation therapy (ART) is among the most important RT techniques which may be utilized for redesigning of treatment plans to account for dynamic changes in tumor size and anatomy during the course of irradiation. In the context of breast cancer, ART may serve as an excellent tool for patients receiving breast irradiation followed by a sequential boost to the tumor bed. Primary benefits of ART include more precise boost localization and potential for improved normal tissue sparing with adapted boost target volumes particularly in the setting of seroma reduction during the course of irradiation. Herein, we provide a concise review of ART for breast cancer in light of the literature.
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Affiliation(s)
- Omer Sager
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Ferrat Dincoglan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Selcuk Demiral
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Bora Uysal
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Hakan Gamsiz
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Fatih Ozcan
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Onurhan Colak
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Yelda Elcim
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Esin Gundem
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Bahar Dirican
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
| | - Murat Beyzadeoglu
- Department of Radiation Oncology, Gulhane Medical Faculty, University of Health Sciences, Etlik, Ankara 06018, Turkey
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Evaluation of adaptive radiotherapy (ART) by use of replanning the tumor bed boost with repeated computed tomography (CT) simulation after whole breast irradiation (WBI) for breast cancer patients having clinically evident seroma. Jpn J Radiol 2018; 36:401-406. [PMID: 29623550 DOI: 10.1007/s11604-018-0735-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/30/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE The aim of this study is to evaluate adaptive radiotherapy (ART) by use of replanning the tumor bed boost with repeated computed tomography (CT) simulation after whole breast irradiation (WBI) for breast cancer patients having clinically evident seroma. MATERIALS AND METHODS Forty-eight patients with clinically evident seroma at the time of planning CT simulation for WBI were included. Two RT treatment plannings were generated for each patient based on the initial CT simulation and tumor bed boost CT simulation to assess seroma and boost target volume (BTV) changes during WBI. Also, dosimetric impact of ART was analyzed by comparative evaluation of critical organ doses in both RT treatment plannings. RESULTS Median time interval between the two CT simulations was 35 days. Statistically significant reduction was detected in seroma volume and BTV during the conventionally fractionated WBI course along with statistically significant reduction in critical organ doses with ART (p < 0.0001). CONCLUSION Our data suggest significant benefit of ART by use of replanning the tumor bed boost with repeated CT simulation after WBI for patients with clinically evident seroma.
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Chiu TD, Parsons D, Zhang Y, Hrycushko B, Zhao B, Chopra R, Kim N, Spangler A, Rahimi A, Timmerman R, Jiang SB, Lu W, Gu X. Prototype volumetric ultrasound tomography image guidance system for prone stereotactic partial breast irradiation: proof-of-concept. Phys Med Biol 2018; 63:055004. [PMID: 29405123 DOI: 10.1088/1361-6560/aaad1f] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Accurate dose delivery in stereotactic partial breast irradiation (S-PBI) is challenging because of the target position uncertainty caused by breast deformation, the target volume changes caused by lumpectomy cavity shrinkage, and the target delineation uncertainty on simulation computed tomography (CT) images caused by poor soft tissue contrast. We have developed a volumetric ultrasound tomography (UST) image guidance system for prone position S-PBI. The system is composed of a novel 3D printed rotation water tank, a patient-specific resin breast immobilization cup, and a 1D array ultrasound transducer. Coronal 2D US images were acquired in 5° increments over a 360° range, and planes were acquired every 2 mm in elevation. A super-compounding technique was used to reconstruct the image volume. The image quality of UST was evaluated with a BB-1 breast phantom and BioZorb surgical marker, and the results revealed that UST offered better soft tissue contrast than CT and similar image quality to MR. In the evaluated plane, the size and location of five embedded objects were measured and compared to MR, which is considered as the ground truth. Objects' diameters and the distances between objects in UST differ by approximately 1 to 2 mm from those in MR, which showed that UST offers the image quality required for S-PBI. In future work we will develop a robotic system that will be ultimately implemented in the clinic.
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Affiliation(s)
- Tsuicheng D Chiu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, United States of America. Tsuicheng Chiu and David Parsons contributed equally to this study
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Aghili M, Barzegartahamtan M, Alikhassi A, Mohammadpour R. Investigation of electron boost radiotherapy in patients with breast cancer: Is a direct electron field optimal? Cancer Radiother 2018; 22:52-56. [PMID: 29398305 DOI: 10.1016/j.canrad.2017.08.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/07/2017] [Accepted: 08/02/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Historically, electron boost dose mainly was delivered by a direct field in adjuvant radiotherapy of breast cancer. In this prospective study, we investigated direct electron field, in terms of optimal coverage of tumour bed volume following localization using ultrasound and surgical clips. MATERIAL AND METHODS First, for all 24 patients, a breast sonographer drew perimeter of tumour bed on the breast skin. Then an electron boost field was outlined on the demarcated territory, and a lead wire marker compatible with CT scan was placed on the field borders by a 2cm margin. After CT scan simulation, all patients underwent adjuvant whole breast irradiation with 3D-conformal radiotherapy to 50Gy in 25 fractions. Then for boost radiotherapy, lead wire in CT images was countoured as electron boost field. Also, the tumour bed was contoured based on surgical clips (true clinical target volume and true planning target volume). Electron treatment planning was done for electron boost field. Finally isodose coverages for true planning target volume investigated. RESULTS On average, 16.68% of clips planning target volume (true planning target volume; range: 0.00 to 95%) received 90% oor more of the prescribed dose when the electron treatment plan was made. Isodose curves does not provide adequate coverage on the tumour bed (clips planning target volume) when electron boost treatment planning was generated for electron boost field (en face electron field). In fact, a part of target (planning target volume-c) is missed and more doses is absorbed in normal tissue. CONCLUSIONS Electron boost treatment planning (an en face electron field) following tumour bed localization using ultrasonography does not provide an optimized coverage of tumour bed volume.
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Affiliation(s)
- M Aghili
- Radiation Oncology Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - M Barzegartahamtan
- Radiation Biology Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - A Alikhassi
- Department of Radiology, Imam Hospital, Tehran University of Medical Sciences, Tehran,Iran
| | - R Mohammadpour
- Department of Biostatistics, Health Sciences Research Centre, Mazandaran University of Medical Sciences, Sari, Iran
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Jeon SH, Shin KH, Park SY, Kim JI, Park JM, Kim JH, Chie EK, Wu HG. Seroma change during magnetic resonance imaging-guided partial breast irradiation and its clinical implications. Radiat Oncol 2017. [PMID: 28633637 PMCID: PMC5477744 DOI: 10.1186/s13014-017-0843-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background To investigate the patterns of post-lumpectomy seroma volume (SV) change and related clinical factors to determine the benefits of adaptive planning in magnetic resonance imaging (MRI)-guided partial breast irradiation (PBI). Methods MRI data obtained from 37 women with early breast cancer acquired at simulation and at the 1st, 6th, and 10th fractions were analyzed. The planning target volume (PTV) was defined as unequal margins of 10–15 mm added according to the directional surgical margin status of each seroma. Treatment was performed using a 0.35 T MRI-guided radiotherapy system. Univariate analysis was performed to assess the correlations between SV change rate and clinical factors. Seroma and PTV for adaptive planning were based on the images obtained at the 6th fraction. Results The average time intervals between surgery-simulation, simulation-1st, 1st-6th, and 6th-10th fractions were 23.1, 8.5, 7.2, and 5.9 days, respectively. Of the 37 patients, 33 exhibited decreased SV over the treatment period. The mean SV of these 33 patients decreased from 100% at simulation to 60, 48, and 40% at each MRI scan. In most cases (26/33), the logarithm of SV was inversely proportional to the elapsed time from surgery (R2 > 0.90, Pearson’s correlation test). The volume of spared normal tissue from adaptive radiotherapy was proportional to the absolute change in SV (R2 = 0.89, Pearson’s correlation test). Conclusion Seromas exhibit exponential shrinkage over the course of PBI. In patients receiving PBI, frequent monitoring of SV could be helpful in decision-making regarding adaptive planning, especially those with a large seroma.
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Affiliation(s)
- Seung Hyuck Jeon
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea. .,Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea. .,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea. .,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea.
| | - So-Yeon Park
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Jung-In Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Jong Min Park
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Hong-Gyun Wu
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul, Republic of Korea
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Major T, Gutiérrez C, Guix B, van Limbergen E, Strnad V, Polgár C. Recommendations from GEC ESTRO Breast Cancer Working Group (II): Target definition and target delineation for accelerated or boost partial breast irradiation using multicatheter interstitial brachytherapy after breast conserving open cavity surgery. Radiother Oncol 2016; 118:199-204. [PMID: 26776444 DOI: 10.1016/j.radonc.2015.12.006] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 12/18/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To prepare guidelines for target definition and delineations after open cavity breast conserving surgery in accelerated partial breast irradiations or boost treatments using multicatheter interstitial brachytherapy based on the consensus of the Breast Working Group of GEC-ESTRO. METHOD Following a study on interobserver variations of target volume delineation in multicatheter breast brachytherapy after open cavity surgery and a number of discussions in consensus meetings these guidelines were worked out by experts on the field. PROPOSED RECOMMENDATIONS (1) Consistent windowing has to be used for proper cavity visualization. (2) The cavity visualization score has to be at least 3 in order to minimize the interobserver variations of target definition. (3) At delineation of surgical cavity only the homogeneous part of the postoperative seroma has to be included in the contours and protrusions or sharp irregularities have to be excluded. When surgical clips are present, they have to be surrounded by the contour with close contact. (4) CTV is created from the outlined surgical cavity with a nonisotropic geometrical extension. In each direction the safety margin is calculated by taking into account the size of the free resection margin. The total size of safety margin is always 20mm which is the sum of the surgical and added safety margins. CTV is limited to chest wall/pectoral muscles and 5mm below the skin surface. CONCLUSION Following these guidelines the target volume definition in breast brachytherapy after open cavity surgery is expected to be accomplished in more consistent way with low interobserver variations.
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Affiliation(s)
- Tibor Major
- Radiotherapy Centre, National Institute of Oncology, Budapest, Hungary
| | - Cristina Gutiérrez
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
| | - Benjamin Guix
- Radiation Oncology, Institute IMOR, Barcelona, Spain
| | - Erik van Limbergen
- Department of Radiotherapy, University Hospital Gasthuisberg, Leuven, Belgium
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Germany
| | - Csaba Polgár
- Radiotherapy Centre, National Institute of Oncology, Budapest, Hungary
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Lewis L, Cox J, Morgia M, Atyeo J, Lamoury G. A clip-based protocol for breast boost radiotherapy provides clear target visualisation and demonstrates significant volume reduction over time. J Med Radiat Sci 2015; 62:177-83. [PMID: 26451239 PMCID: PMC4592671 DOI: 10.1002/jmrs.114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 04/01/2015] [Accepted: 04/21/2015] [Indexed: 12/27/2022] Open
Abstract
Introduction The clinical target volume (CTV) for early stage breast cancer is difficult to clearly identify on planning computed tomography (CT) scans. Surgical clips inserted around the tumour bed should help to identify the CTV, particularly if the seroma has been reabsorbed, and enable tracking of CTV changes over time. Methods A surgical clip-based CTV delineation protocol was introduced. CTV visibility and its post-operative shrinkage pattern were assessed. The subjects were 27 early stage breast cancer patients receiving post-operative radiotherapy alone and 15 receiving post-operative chemotherapy followed by radiotherapy. The radiotherapy alone (RT/alone) group received a CT scan at median 25 days post-operatively (CT1rt) and another at 40 Gy, median 68 days (CT2rt). The chemotherapy/RT group (chemo/RT) received a CT scan at median 18 days post-operatively (CT1ch), a planning CT scan at median 126 days (CT2ch), and another at 40 Gy (CT3ch). Results There was no significant difference (P = 0.08) between the initial mean CTV for each cohort. The RT/alone cohort showed significant CTV volume reduction of 38.4% (P = 0.01) at 40 Gy. The Chemo/RT cohort had significantly reduced volumes between CT1ch: median 54 cm3 (4–118) and CT2ch: median 16 cm3, (2–99), (P = 0.01), but no significant volume reduction thereafter. Conclusion Surgical clips enable localisation of the post-surgical seroma for radiotherapy targeting. Most seroma shrinkage occurs early, enabling CT treatment planning to take place at 7 weeks, which is within the 9 weeks recommended to limit disease recurrence.
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Affiliation(s)
- Lorraine Lewis
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital Sydney, New South Wales, Australia
| | - Jennifer Cox
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital Sydney, New South Wales, Australia ; Faculty of Health Sciences, University of Sydney Sydney, New South Wales, Australia
| | - Marita Morgia
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital Sydney, New South Wales, Australia
| | - John Atyeo
- Faculty of Health Sciences, University of Sydney Sydney, New South Wales, Australia
| | - Gillian Lamoury
- Department of Radiation Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital Sydney, New South Wales, Australia
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Patel H, Goyal S, Kim L. Using injectable hydrogel markers to assess resimulation for boost target volume definition in a patient undergoing whole-breast radiotherapy. Med Dosim 2015; 40:352-4. [PMID: 26051069 DOI: 10.1016/j.meddos.2015.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 02/16/2015] [Accepted: 04/27/2015] [Indexed: 11/27/2022]
Abstract
Several publications have recommended that patients undergoing whole-breast radiotherapy be resimulated for boost planning. The rationale for this is that the seroma may be smaller when compared with the initial simulation. However, the decision remains whether to use the earlier or later images to define an appropriate boost target volume. A patient undergoing whole-breast radiotherapy had new, injectable, temporary hydrogel fiducial markers placed 1 to 3cm from the seroma at the time of initial simulation. The patient was resimulated 4.5 weeks later for conformal photon boost planning. Computed tomography (CT) scans acquired at the beginning and the end of whole-breast radiotherapy showed that shrinkage of the lumpectomy cavity was not matched by a corresponding reduction in the surrounding tissue volume, as demarcated by hydrogel markers. This observation called into question the usual interpretation of cavity shrinkage for boost target definition. For this patient, it was decided to define the boost target volume on the initial planning CT instead of the new CT.
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Affiliation(s)
- Henal Patel
- Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, Piscataway, NJ
| | - Sharad Goyal
- Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick, NJ
| | - Leonard Kim
- Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick, NJ.
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Smith S, Comins C. Radiographer-led breast boost localisation – A service evaluation study. Radiography (Lond) 2015. [DOI: 10.1016/j.radi.2014.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ultrasound Accuracy in Determining the Tumor Depth for Boost Field Radiotherapy in Breast Cancer in Comparison With CT Scan Plus Clips. REPORTS OF RADIOTHERAPY AND ONCOLOGY 2015. [DOI: 10.5812/rro.2(1)2015.887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chen X, Qiao Q, DeVries A, Li W, Currey A, Kelly T, Bergom C, Wilson JF, Li XA. Adaptive replanning to account for lumpectomy cavity change in sequential boost after whole-breast irradiation. Int J Radiat Oncol Biol Phys 2014; 90:1208-15. [PMID: 25442046 DOI: 10.1016/j.ijrobp.2014.08.342] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 08/16/2014] [Accepted: 08/25/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate the efficiency of standard image-guided radiation therapy (IGRT) to account for lumpectomy cavity (LC) variation during whole-breast irradiation (WBI) and propose an adaptive strategy to improve dosimetry if IGRT fails to address the interfraction LC variations. METHODS AND MATERIALS Daily diagnostic-quality CT data acquired during IGRT in the boost stage using an in-room CT for 19 breast cancer patients treated with sequential boost after WBI in the prone position were retrospectively analyzed. Contours of the LC, treated breast, ipsilateral lung, and heart were generated by populating contours from planning CTs to boost fraction CTs using an auto-segmentation tool with manual editing. Three plans were generated on each fraction CT: (1) a repositioning plan by applying the original boost plan with the shift determined by IGRT; (2) an adaptive plan by modifying the original plan according to a fraction CT; and (3) a reoptimization plan by a full-scale optimization. RESULTS Significant variations were observed in LC. The change in LC volume at the first boost fraction ranged from a 70% decrease to a 50% increase of that on the planning CT. The adaptive and reoptimization plans were comparable. Compared with the repositioning plans, the adaptive plans led to an improvement in target coverage for an increased LC case (1 of 19, 7.5% increase in planning target volume evaluation volume V95%), and breast tissue sparing for an LC decrease larger than 35% (3 of 19, 7.5% decrease in breast evaluation volume V50%; P=.008). CONCLUSION Significant changes in LC shape and volume at the time of boost that deviate from the original plan for WBI with sequential boost can be addressed by adaptive replanning at the first boost fraction.
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Affiliation(s)
- Xiaojian Chen
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Qiao Qiao
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Radiotherapy, First Hospital of China Medical University, Shenyang, China
| | - Anthony DeVries
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wenhui Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Radiotherapy, Yunnan Tumor Hospital, Kunming, China
| | - Adam Currey
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracy Kelly
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Carmen Bergom
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - J Frank Wilson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
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den Hartogh MD, Philippens MEP, van Dam IE, Kleynen CE, Tersteeg RJHA, Pijnappel RM, Kotte ANTJ, Verkooijen HM, van den Bosch MAAJ, van Vulpen M, van Asselen B, van den Bongard HJGD. MRI and CT imaging for preoperative target volume delineation in breast-conserving therapy. Radiat Oncol 2014; 9:63. [PMID: 24571783 PMCID: PMC3942765 DOI: 10.1186/1748-717x-9-63] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 02/14/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Accurate tumor bed delineation after breast-conserving surgery is important. However, consistency among observers on standard postoperative radiotherapy planning CT is low and volumes can be large due to seroma formation. A preoperative delineation of the tumor might be more consistent. Therefore, the purpose of this study was to determine the consistency of preoperative target volume delineation on CT and MRI for breast-conserving radiotherapy. METHODS Tumors were delineated on preoperative contrast-enhanced (CE) CT and newly developed 3D CE-MR images, by four breast radiation oncologists. Clinical target volumes (CTVs) were created by addition of a 1.5 cm margin around the tumor, excluding skin and chest wall. Consistency in target volume delineation was expressed by the interobserver variability. Therefore, the conformity index (CI), center of mass distance (dCOM) and volumes were calculated. Tumor characteristics on CT and MRI were scored by an experienced breast radiologist. RESULTS Preoperative tumor delineation resulted in a high interobserver agreement with a high median CI for the CTV, for both CT (0.80) and MRI (0.84). The tumor was missed on CT in 2/14 patients (14%). Leaving these 2 patients out of the analysis, CI was higher on MRI compared to CT for the GTV (p<0.001) while not for the CTV (CT (0.82) versus MRI (0.84), p=0.123). The dCOM did not differ between CT and MRI. The median CTV was 48 cm3 (range 28-137 cm3) on CT and 59 cm3 (range 30-153 cm3) on MRI (p<0.001). Tumor shapes and margins were rated as more irregular and spiculated on CE-MRI. CONCLUSIONS This study showed that preoperative target volume delineation resulted in small target volumes with a high consistency among observers. MRI appeared to be necessary for tumor detection and the visualization of irregularities and spiculations. Regarding the tumor delineation itself, no clinically relevant differences in interobserver variability were observed. These results will be used to study the potential for future MRI-guided and neoadjuvant radiotherapy. TRIAL REGISTRATION International Clinical Trials Registry Platform NTR3198.
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Affiliation(s)
- Mariska D den Hartogh
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marielle EP Philippens
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Iris E van Dam
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Catharina E Kleynen
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Robbert JHA Tersteeg
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ruud M Pijnappel
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexis NTJ Kotte
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Helena M Verkooijen
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marco van Vulpen
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Bram van Asselen
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - HJG Desirée van den Bongard
- Department of Radiotherapy, University Medical Center Utrecht, HP Q00.118, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Yue NJ, Haffty BG, Kearney T, Kirstein L, Chen S, Goyal S. Tracking the dynamic seroma cavity using fiducial markers in patients treated with accelerated partial breast irradiation using 3D conformal radiotherapy. Med Phys 2013; 40:021717. [PMID: 23387740 DOI: 10.1118/1.4788644] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The purpose of the present study was to perform an analysis of the changes in the dynamic seroma cavity based on fiducial markers in early stage breast cancer patients treated with accelerated partial breast irradiation (APBI) using three-dimensional conformal external beam radiotherapy (3D-CRT). METHODS A prospective, single arm trial was designed to investigate the utility of gold fiducial markers in image guided APBI using 3D-CRT. At the time of lumpectomy, four to six suture-type gold fiducial markers were sutured to the walls of the cavity. Patients were treated with a fractionation scheme consisting of 15 fractions with a fractional dose of 333 cGy. Treatment design and planning followed NSABP∕RTOG B-39 guidelines. During radiation treatment, daily kV imaging was performed and the markers were localized and tracked. The change in distance between fiducial markers was analyzed based on the planning CT and daily kV images. RESULTS Thirty-four patients were simulated at an average of 28 days after surgery, and started the treatment on an average of 39 days after surgery. The average intermarker distance (AiMD) between fiducial markers was strongly correlated to seroma volume. The average reduction in AiMD was 19.1% (range 0.0%-41.4%) and 10.8% (range 0.0%-35.6%) for all the patients between simulation and completion of radiotherapy, and between simulation and beginning of radiotherapy, respectively. The change of AiMD fits an exponential function with a half-life of seroma shrinkage. The average half-life for seroma shrinkage was 15 days. After accounting for the reduction which started to occur after surgery through CT simulation and treatment, radiation was found to have minimal impact on the distance change over the treatment course. CONCLUSIONS Using the marker distance change as a surrogate for seroma volume, it appears that the seroma cavity experiences an exponential reduction in size. The change in seroma size has implications in the size of the CTV, PTV, and percent of normal breast tissue irradiated when using 3D-CRT.
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Affiliation(s)
- Ning J Yue
- Department of Radiation Oncology, UMDNJ∕Robert Wood Johnson Medical School, New Brunswick, NJ 08903, USA
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15
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Truong MT, Hirsch AE, Kovalchuk N, Qureshi MM, Damato A, Schuller B, Vassilakis N, Stone M, Gierga D, Willins J, Kachnic LA. Cone-beam computed tomography image guided therapy to evaluate lumpectomy cavity variation before and during breast radiotherapy. J Appl Clin Med Phys 2013; 14:4243. [PMID: 23470944 PMCID: PMC5714375 DOI: 10.1120/jacmp.v14i2.4243] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 11/21/2012] [Accepted: 11/30/2012] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to evaluate the rate of change (RoC) in the size of the lumpectomy cavity (LC) before and during breast radiotherapy (RT) using cone‐beam computed tomography (CBCT), relative to the initial LC volume at CT simulation (CTVLC) and timing from surgery. A prospective institutional review board‐approved study included 26 patients undergoing breast RT: 20 whole breast irradiation (WBI) patients and six partial breast irradiation (PBI) patients, with surgical clips outlining the LC. The patients underwent CT simulation (CTsim) followed by five CBCTs during RT, once daily for PBI and once weekly for WBI. The distance between surgical clips and their centroid (D) acted as a surrogate for LC size. The RoC of the LC size, defined as the percentage change of D between two scans divided by the time interval in days between the scans, was calculated before (CTsim to CBCT1) and during RT (CBCT1 to CBCT5). The mean RoC of D for all patients before starting RT was −0.25%/day (range, −1.3 to 1.4) and for WBI patients during RT was −0.15%/day (range, −0.45 to 0.40). Stratified by median CTVLC, the RoC before RT for large CTVLC group (≥25.7cc) was 15 times higher (−0.47%/day) than for small CTVLC group (<25.7 cc) (−0.03%/day), p=0.06. For patients undergoing CTsim< 42 days from surgery, the RoC before RT was −0.43%/day compared to −0.07%/day for patients undergoing CTsim≥42 days from surgery, p=0.12. For breast cancer RT, the rate of change of the LC is affected by the initial cavity size and the timing from surgery. Resimulation closer to the time of boost treatment should be considered in patients who are initially simulated within six weeks of surgery and/or with large CTVLC. PACS number: 87.55.de
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Affiliation(s)
- Minh Tam Truong
- Department of Radiation Oncology, Boston University School of Medicine, Boston, MA, USA.
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16
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Impact of interfraction seroma collection on breast brachytherapy dosimetry - a mathematical model. J Contemp Brachytherapy 2013; 4:101-5. [PMID: 23349651 PMCID: PMC3552631 DOI: 10.5114/jcb.2012.29366] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/04/2012] [Accepted: 05/03/2012] [Indexed: 11/17/2022] Open
Abstract
Purpose Balloon brachytherapy is a widely accepted modality for delivery of accelerated partial breast irradiation (APBI). Our hypothesis was that inter-fraction seroma collection around the balloon surface would have an adverse effect on dosimetry of the target. Material and methods This is a dosimetric re-planning study using two volumetric models (30 cc and 45 cc) in a Contura® multi-lumen balloon (MLB) catheter. In a previously treated patient, two customized baseline plans were generated using multiple channels of the Contura® catheter prescribed to the Planning Target Volume Evaluation (PTV_Eval). Symmetric expansions of 1.0 mm (0-9 mm) increments around the balloon surface were performed to simulate a “Virtual Seroma” (VS) accumulation for both balloon volumes and plans were obtained for each expansion using Eclipse Brachyvision™. An analysis of these plans was then performed to evaluate the effect of seroma accumulation on dosimetric parameters of V100 and V90. Results 20 plans were generated and analyzed (10 plans for each balloon volume), representing VS of 6.0-66.0 cc. There was a commensurate decrease in the dose delivered to the PTV_Eval V100 and V90 (as defined by the original treatment plan) with increasing VS accumulation leading to a sub-optimal coverage of the PTV_Eval. For 30 cc MLB catheter, V100 decreased by 1.4% and V90 decreased by 0.9% for every 1 cc of VS. For 45cc MLB catheter, V100 decreased by 1.3% and V90 decreased by 1.15% for every 1.0 cc accumulation of VS. Conclusions Balloon catheter-tissue adherence ensures daily dose delivery to the planned PTV_Eval. Accumulation of seroma, hematoma or air between HDR fractions can significantly impact PTV_Eval dosimetry. Vacuum-port aspiration prior to delivery of each fraction, if available, should be considered to minimize the risk of geographic under dosing.
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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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18
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Yang Z, Chen J, Xie J, Zhu C, Pan Z, Yu X, Mei X, Fu X, Guo X. Simultaneous integrated boost in breast conserving radiotherapy: is replanning necessary following tumor bed change? Technol Cancer Res Treat 2012; 12:115-22. [PMID: 23098285 DOI: 10.7785/tcrt.2012.500309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Tumor bed (TB) change is often seen during the whole breast irradiation (WBI) in early breast cancer patients. The aims of this study were to evaluate change in seroma volume on repeat CTs and to explore whether replanning is necessary in breast conserving radiotherapy (RT) using the intensity modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB). Thirty patients underwent WBI with 84 CT scans (24 with 3 CTs (CT1, CT2 and CT3) and 6 without CT3) during the 6 weeks of RT were reviewed. TB and other target volumes on all CTs were delineated and compared. IMRT-SIB treatment plans with 50.68 Gy to the whole breast and 64.4 Gy to the boost in 28 fractions were constructed in the CT1. Replan and hybrid plan (without replanning) in the CT2 were reproduced. Dosimetric differences between the replans and hybrid plans were also compared. The mean TB volumes for CT1, CT2 and CT3 were 42.1 cm(3), 20.1 cm(3), 17.0 cm(3), respectively. The mean TB volume reduction was 40.5% from the CT1 to CT2 and 4.3% from the CT2 to CT3. The difference of TB volumes between the CT1 and CT2 was statistically significance (p < 0.001), but not significant between the CT2 and CT3 (p = 1.000). For all patients, target coverage remained adequate with either hybrid plans or replans. However, replanning can significantly decrease the whole breast mean dose (35.2 vs. 35.6 Gy, p = 0.026) and breast volume outside the boost receiving 95% of the boost prescribed dose (39.5 vs. 68.2 cm(3), p < 0.001). In summary, boost volume could irradiate adequately after the significance shrinkage of tumor bed with the fractionated schedule of IMRT-SIB, but replanning on a second CT could avoid the undesired high dose irradiated breast tissue outside boost.
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Affiliation(s)
- ZhaoZhi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
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19
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Acevedo-Henao CM, Heymann S, Rossier C, Garbay JR, Arnedos M, Balleyguier C, Ferchiou M, Marsiglia H, Bourgier C. [Conformal accelerated partial breast irradiation: state of the art]. Cancer Radiother 2012; 16:641-9. [PMID: 22727723 DOI: 10.1016/j.canrad.2012.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 03/09/2012] [Accepted: 03/27/2012] [Indexed: 11/26/2022]
Abstract
Breast conserving treatment (breast conserving surgery followed by whole breast irradiation) has commonly been used in early breast cancer since many years. New radiation modalities have been recently developed in early breast cancers, particularly accelerated partial breast irradiation. Three-dimensional conformal accelerated partial breast irradiation is the most commonly used modality of radiotherapy. Other techniques are currently being developed, such as intensity-modulated radiotherapy, arctherapy, and tomotherapy. The present article reviews the indications, treatment modalities and side effects of accelerated partial breast irradiation.
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Affiliation(s)
- C-M Acevedo-Henao
- Département de radiothérapie, institut de cancérologie Gustave-Roussy, Villejuif cedex, France
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20
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Keller BM, Ravi A, Sankreacha R, Pignol JP. Permanent Breast Seed Implant Dosimetry Quality Assurance. Int J Radiat Oncol Biol Phys 2012; 83:84-92. [DOI: 10.1016/j.ijrobp.2011.05.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 05/10/2011] [Accepted: 05/15/2011] [Indexed: 11/30/2022]
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Decrease of the lumpectomy cavity volume after whole-breast irradiation affects small field boost planning. Med Dosim 2012; 37:339-43. [PMID: 22305933 DOI: 10.1016/j.meddos.2011.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 11/16/2011] [Accepted: 11/29/2011] [Indexed: 12/27/2022]
Abstract
To determine whether small field boost (SFB) replanning is necessary when the lumpectomy cavity (LPC) decreases during whole-breast irradiation (WBI) and what parameters might predict a change in the SFB plan. Forty patients had computed tomography (CT) simulation (CT1) within 60 days of surgery and were resimulated (CT2) after 37.8-41.4 Gy for SFB planning. A 3-field photon plan and a single en face electron plan were created on both CTs and compared. In the 26 patients who had a ≥5 cm(3) and a ≥25% decrease in lumpectomy cavity volume (LCV) between CT scans, the SFB plan using photons was different in terms of normal breast tissue volume irradiated (BTV) (p < 0.001), and field dimensions (p < 0.001). In 20/35 patients, the energy or field size changed for electron plans on CT2, but no tested characteristics predicted for a change. Less BTV was irradiated using electrons than photons in 29% (CT1) to 37% (CT2). SFB replanning needs to be individualized to each patient because of the variety of factors that can impact dosimetric planning. Replanning is recommended when using 3-field photons if the patient has experienced a ≥5 cm(3) and a ≥25% decrease in LCV during WBI. Some patients may benefit from electron SFB replanning but no tested characteristics reliably predict those who may benefit the most. The amount of BTV irradiated is less with electrons than in photon plans and this has the potential to improve cosmesis, a clinically important outcome in breast-conserving therapy.
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22
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Cho H, Kim C. Volumetric changes in the lumpectomy cavity during whole breast irradiation after breast conserving surgery. Radiat Oncol J 2011; 29:277-82. [PMID: 22984681 PMCID: PMC3429913 DOI: 10.3857/roj.2011.29.4.277] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 10/28/2011] [Accepted: 10/28/2011] [Indexed: 12/28/2022] Open
Abstract
Purpose This study was performed to evaluate the change in the lumpectomy cavity volumes before and after whole breast radiation therapy (WBRT) and to identify factors associated with the change of volume. Materials and Methods From September 2009 to April 2010, the computed tomography (CT) simulation data from 70 patients obtained before and after WBRT was evaluated. The lumpectomy cavity volumes were contoured based on surgical clips, seroma, and postoperative changes. Significant differences in the data from pre-WBRT CT and post-WBRT CT were assessed. Multiple variables were examined for correlation with volume reduction in the lumpectomy cavity. Results The mean and median volume reduction in the lumpectomy cavity after WBRT were 17.6 cm3 and 16.1 cm3, respectively with the statistical significance (p < 0.001). The volume reduction in the lumpectomy cavity was inversely correlated with time from surgery to radiation therapy (R = 0.390). The presence of seroma was significantly associated with a volumetric change in the lumpectomy cavity after WBRT (p = 0.011). Conclusion The volume of lumpectomy cavity reduced significantly after WBRT. As the time from surgery to the start of WBRT increased, the volume reduction in the lumpectomy cavity during WBRT decreased. A strong correlation was observed between the presence of seroma and the reduced volume. To ensure appropriate coverage and to limit normal tissue exposure during boost irradiation in patients who has seroma at the time of starting WBRT, repeating CT simulation at boost planning is suggested.
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Affiliation(s)
- Heunglae Cho
- Department of Radiation Oncology, Inje University College of Medicine, Busan, Korea
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Bhatt AD, Crew JB, Bhatt G, Johnson RR, Sowards KT, Pan J, Dragun AE. Interfraction accumulation of seroma during accelerated partial breast irradiation: preliminary results of a prospective study. Brachytherapy 2011; 11:374-9. [PMID: 21820365 DOI: 10.1016/j.brachy.2011.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Revised: 06/21/2011] [Accepted: 06/29/2011] [Indexed: 11/17/2022]
Abstract
PURPOSE To quantify and characterize the process of seroma accumulation during accelerated partial breast irradiation using multicatheter balloon brachytherapy. MATERIALS AND METHODS Twenty-two patients were treated using the Contura Multilumen brachytherapy catheter to a dose of 34Gy in 10 fractions over 5 treatment days. Serial aspirations of the vacuum port of the catheter were performed at the time of CT simulation and before each treatment. Volume and characteristics of fluid drawn were recorded. Univariate analysis was performed to evaluate various factors predictive of seroma formation. RESULTS Median patient age was 59.5 years, body mass index was 31, and volume of surgical specimen was 62.4cm(3). Median time from breast conservation surgery to placement of Contura catheter was 18.5 days. Pericatheter seroma, typically scant with a median volume of 0.75mL, was noted in 91% of patients at CT simulation. A total of 203 aspirations were performed with a median-aspirated seroma volume of 4.05mL. There was no significant correlation between the volume of seroma and histology (invasive vs. in situ), quadrant of location, body mass index, reexcision or reoperation, days from breast conservation surgery to balloon placement, or the volume of specimen removed. Radiation treatment factors, including balloon volume, balloon to skin distance, and planning target volume evaluation, also did not correlate with aspirated seroma. CONCLUSIONS Interfraction seroma accumulation has a variable pattern of development with no discernible predictors of occurrence. Routine pretreatment aspirations via vacuum port may potentially improve dosimetric reproducibility for a minority of patients.
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Affiliation(s)
- Aashish D Bhatt
- Department of Radiation Oncology, James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY 40202, USA.
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Alderliesten T, den Hollander S, Yang TIJ, Elkhuizen PHM, van Mourik AM, Hurkmans C, Remeijer P, van Vliet-Vroegindeweij C. Dosimetric impact of post-operative seroma reduction during radiotherapy after breast-conserving surgery. Radiother Oncol 2011; 100:265-70. [PMID: 21497929 DOI: 10.1016/j.radonc.2011.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 03/17/2011] [Accepted: 03/20/2011] [Indexed: 12/27/2022]
Abstract
PURPOSE Three boost radiotherapy (RT) techniques were compared to evaluate the dosimetric effect of seroma reduction during RT after breast-conserving surgery (BCS). MATERIALS AND METHODS Twenty-one patients who developed seroma after BCS were included. Each patient underwent three CT scans: one week before RT (CT(-1)), in the third (CT(3)) and fifth (CT(5)) week of RT. For each patient, three plans were generated. (1) SEQ: whole breast irradiation planned on CT(-1,) sequential boost planned on CT(5), (2) SIB: simultaneous integrated boost planned on CT(-1), (3) SIB adaptive radiation therapy (SIB-ART): planned on CT(-1) and re-planned on CT(3). Irradiated volumes, mean lung (MLD) and maximum heart dose (HD(max)) were projected and compared on CT(5). RESULTS On average 62% seroma reduction during RT was observed. Volumes receiving ≥ 107% of prescribed whole breast dose were significantly smaller with SIB-ART compared to SEQ and SIB. The undesired volume receiving ≥ 95% of prescribed total dose was also significantly smaller with SIB-ART. For SEQ, SIB-ART and SIB, respectively, small but significant differences were found in MLD (4.2 vs. 4.6 vs. 4.7 Gy) and in HD(max) for patients with left-sided breast cancer (39.9 vs. 35.8 vs. 36.9 Gy). CONCLUSIONS This study demonstrates a dosimetric advantage for patients with seroma when simultaneous integrated boost is used with re-planning halfway through treatment.
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Affiliation(s)
- Tanja Alderliesten
- Department of Radiation Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Practical use of the extended no action level (eNAL) correction protocol for breast cancer patients with implanted surgical clips. Int J Radiat Oncol Biol Phys 2011; 82:1031-7. [PMID: 21420248 DOI: 10.1016/j.ijrobp.2010.12.059] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 12/10/2010] [Accepted: 12/27/2010] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe the practical use of the extended No Action Level (eNAL) setup correction protocol for breast cancer patients with surgical clips and evaluate its impact on the setup accuracy of both tumor bed and whole breast during simultaneously integrated boost treatments. METHODS AND MATERIALS For 80 patients, two orthogonal planar kilovoltage images and one megavoltage image (for the mediolateral beam) were acquired per fraction throughout the radiotherapy course. For setup correction, the eNAL protocol was applied, based on registration of surgical clips in the lumpectomy cavity. Differences with respect to application of a No Action Level (NAL) protocol or no protocol were quantified for tumor bed and whole breast. The correlation between clip migration during the fractionated treatment and either the method of surgery or the time elapsed from last surgery was investigated. RESULTS The distance of the clips to their center of mass (COM), averaged over all clips and patients, was reduced by 0.9 ± 1.2 mm (mean ± 1 SD). Clip migration was similar between the group of patients starting treatment within 100 days after surgery (median, 53 days) and the group starting afterward (median, 163 days) (p = 0.20). Clip migration after conventional breast surgery (closing the breast superficially) or after lumpectomy with partial breast reconstructive techniques (sutured cavity). was not significantly different either (p = 0.22). Application of eNAL on clips resulted in residual systematic errors for the clips' COM of less than 1 mm in each direction, whereas the setup of the breast was within about 2 mm of accuracy. CONCLUSIONS Surgical clips can be safely used for high-accuracy position verification and correction. Given compensation for time trends in the clips' COM throughout the treatment course, eNAL resulted in better setup accuracies for both tumor bed and whole breast than NAL.
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Yang TIJ, Minkema D, Elkhuizen PH, Heemsbergen W, van Mourik AM, van Vliet-Vroegindeweij C. Clinical Applicability of Cone-Beam Computed Tomography in Monitoring Seroma Volume Change During Breast Irradiation. Int J Radiat Oncol Biol Phys 2010; 78:119-26. [DOI: 10.1016/j.ijrobp.2009.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 07/07/2009] [Indexed: 10/20/2022]
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Strauss JB, Gielda BT, Chen SS, Shah AP, Abrams RA, Griem KL. Variation in Post-Surgical Lumpectomy Cavity Volume With Delay in Initiation of Breast Irradiation Because of Chemotherapy. Int J Radiat Oncol Biol Phys 2010; 77:831-5. [DOI: 10.1016/j.ijrobp.2009.05.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 05/28/2009] [Accepted: 05/29/2009] [Indexed: 11/16/2022]
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Kim LH, DeCesare S, Vicini F, Yan D. Effect of lumpectomy cavity volume change on the clinical target volume for accelerated partial breast irradiation: a deformable registration study. Int J Radiat Oncol Biol Phys 2010; 78:1121-6. [PMID: 20207493 DOI: 10.1016/j.ijrobp.2009.09.077] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Revised: 09/16/2009] [Accepted: 09/17/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE Previous studies have shown that lumpectomy cavity volumes can change significantly in the weeks following surgery. The effect of this volume change on the surrounding tissue that constitutes the clinical target volume (CTV) for accelerated partial breast irradiation and boost treatment after whole breast irradiation has not been previously studied. In the present study, we used deformable registration to estimate the effect of lumpectomy cavity volume changes on the CTV for accelerated partial breast irradiation and discuss the implications for target construction. METHODS AND MATERIALS The data from 13 accelerated partial breast irradiation patients were retrospectively analyzed. Deformable registration was used to propagate contours from the initial planning computed tomography scan to a later computed tomography scan acquired at the start of treatment. The changes in cavity volume and CTV, distance between cavity and CTV contours (i.e., CTV margin), and CTV localization error after cavity registration were determined. RESULTS The mean ± standard deviation change in cavity volume and CTV between the two computed tomography scans was -35% ± 23% and -14% ± 12%, respectively. An increase in the cavity-to-CTV margin of 2 ± 2 mm was required to encompass the CTV, and this increase correlated with the cavity volume change. Because changes in the cavity and CTV were not identical, a localization error of 2-3 mm in the CTV center of mass occurred when the cavity was used as the reference for image guidance. CONCLUSION Deformable registration suggested that CTV margins do not remain constant as the cavity volume changes. This finding has implications for planning target volume and CTV construction.
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Affiliation(s)
- Leonard H Kim
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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