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Takahashi K, Kagami Y, Yoshimura R, Morota M, Murakami N, Nakamura S, Okamoto H, Nagao A, Sakuramachi M, Kashihara T, Kaneda T, Inaba K, Okuma K, Nakayama Y, Itami J, Igaki H. Prospective study of once-daily accelerated partial breast irradiation using 3-dimensional conformal external beam radiotherapy for Japanese women: 12-year outcomes, toxicity, and cosmesis. Breast Cancer 2025; 32:197-207. [PMID: 39630209 PMCID: PMC11717833 DOI: 10.1007/s12282-024-01650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 11/09/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND To analyze in a prospective study the long-term safety and efficacy of 3-dimensional conformal radiotherapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI) for Japanese women with early breast cancer. METHODS Breast cancer patients with pathological tumor size ≤ 3 cm, age ≥ 20 years, lumpectomy with at least a 5 mm margin, and ≤ 3 positive axillary nodes were eligible. APBI was delivered by 3D-CRT at a dose of 38.5 Gy in 10 fractions over 10 days. The primary endpoints were the frequency and severity of acute and late radiation toxicities, and secondary endpoints were local control, survival, and cosmesis. The sample size was determined based on the incidence of ≥ grade 3 acute and late radiation toxicities, which required 71 enrollments. RESULTS Between 2008 and 2010, 73 patients enrolled in this trial. Twelve patients (16%) had 1-3 lymph node metastases. At a median follow-up of 12.6 years (range: 2.7-13.9 years), there were no cases of grade ≥ 3 acute or late toxicity. There were 4 ipsilateral breast tumor recurrence (IBTR) events: 12-year IBTR incidence was 4.4%. The difference in the incidence of IBTR between node-negative and node-positive patients was marginal (1.9% vs. 16.7%, p = 0.055). The majority of patients (94.4% at 2 years, 89.3% at 10 years after enrollment) had excellent/good cosmesis. CONCLUSIONS APBI delivered with 3D-CRT is a feasible treatment option for Asian females, but it was indicated that node-positive status might increase IBTR risk.
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Affiliation(s)
- Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Yoshikazu Kagami
- Department of Radiation Oncology, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Ryoichi Yoshimura
- Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Madoka Morota
- Department of Radiation Oncology, Showa University Koto Toyosu Hospital, 5-1-38 Toyosu, Koto-ku, Tokyo, 135-0061, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Satoshi Nakamura
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hiroyuki Okamoto
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Madoka Sakuramachi
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tomoya Kaneda
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yuko Nakayama
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Jun Itami
- Shin-Matsudo Accuracy Radiation Therapy Center, Shin-Matsudo Central General Hospital, Shin-Matsudo 1-380, Matsudo-City, Chiba, 270-0034, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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Lapen K, Fiasconaro M, Zhang Z, Abaya A, McCormick B, Xu AJ, Cuaron J, Powell SN, Kahn AJ, Gillespie EF, Braunstein LZ. Accelerated Partial Breast Irradiation: Association of Dosimetric Parameters With Patient-Reported Outcomes. Adv Radiat Oncol 2023; 8:101263. [PMID: 37305071 PMCID: PMC10248091 DOI: 10.1016/j.adro.2023.101263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/25/2023] [Indexed: 06/13/2023] Open
Abstract
Purpose Accelerated partial breast irradiation (APBI) after breast-conserving surgery offers a well-tolerated adjuvant radiation therapy option for patients with breast cancer. We sought to describe patient-reported acute toxicity as a function of salient dosimetric parameters during and after an APBI regimen of 40 Gy in 10 once-daily fractions. Methods and Materials From June 2019 to July 2020, patients undergoing APBI were assigned a weekly, response-adapted, patient reported outcomes-common terminology criteria for adverse events-based acute toxicity assessment. Patients reported acute toxicity during treatment and for up to 8 weeks after treatment. Dosimetric treatment parameters were collected. Descriptive statistics and univariable analyses were used to summarize patient-reported outcomes and their correlation to corresponding dosimetric measures, respectively. Results Overall, 55 patients who received APBI completed a total of 351 assessments. Median planning target volume was 210 cc (range, 64-580 cc), and median planning target volume:ipsilateral breast volume ratio was 0.17 (range, 0.05-0.44). Overall, 22% of patients reported moderate breast enlargement and 27% reported maximum skin toxicity as severe or very severe. Furthermore, 35% of patients reported fatigue, and 44% of patients reported pain in the radiated area as moderate to very severe. Median time to first report of any moderate to very severe symptom was 10 days (interquartile range, 6-27 days). By 8 weeks after APBI, most patients reported resolution of symptoms, with 16% reporting residual moderate symptoms. Upon univariable analysis, none of the ascertained salient dosimetric parameters were associated with maximum symptoms or with the presence of moderate to very severe toxicity. Conclusions Weekly assessments during and after APBI showed that patients experienced moderate to very severe toxicities, most commonly skin toxicity, but that these typically resolved by 8 weeks after radiation therapy. More comprehensive evaluations among larger cohorts are warranted to define the precise dosimetric parameters that correspond to outcomes of interest.
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Affiliation(s)
- Kaitlyn Lapen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Megan Fiasconaro
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anthony Abaya
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J. Kahn
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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Li Y, Shui L, Wang X, Sun Y, Zhong R, Shui P, Chen N. Long-Term Results of Partial Breast Irradiation After Breast-Conserving Surgery for Early Stage Breast Cancer: A Prospective Phase II Trial in China. Front Oncol 2020; 10:550950. [PMID: 32984062 PMCID: PMC7492676 DOI: 10.3389/fonc.2020.550950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 08/13/2020] [Indexed: 02/05/2023] Open
Abstract
Background Partial breast radiotherapy (PBI) has emerged as an option after breast-conserving surgery for early stage breast cancer patients. Methods A total of 55 patients with early stage breast cancer between 2009 and 2013 were enrolled in this single-institutional phase II prospective clinical trial. All patients received adjuvant PBI-IMRT after lumpectomy, with the prescription of 48 Gy in 12 fractions at 4 Gy per fraction, 5 days a week. The primary endpoint was ipsilateral breast tumor recurrence (IBTR), the other endpoints were a regional nodal failure (RNF), distant metastasis (DM) rate, disease-free survival (DFS), and overall survival (OS). These endpoints were used to evaluate clinical outcomes. The cosmetic effects and the late toxicity were assessed according to Harvard standard scale and CTCAE 3.0, respectively. Results In our cohorts, the median age was 45.60 years old (range 31-65 years) and 29.09% of these patients were post-menopause (n = 16). Most patients were T1 stage (65.45%) or N0 stage (70.91%). 80% of patients were ER-positive, 67.27% PR positive, and 61.82% HER2 negative. At the median follow-up of 9.25 years, RNF was 0% and IBTR occurred in only one patient (1.82%) to the chest wall. Except for one patient (1.82%) had DM to lung and pleura and died from disease progression, the remaining patients were alive at the end of the 10-year follow-up. The 10-year DFS and OS were 94.55 and 98.18%. One patient (1.82%) was diagnosed with endometrial cancer after PBI. Except for 9 patients who declined the cosmetic assessment, the rest of the 46 patients (83.64%) were all rated as good and well-satisfied with the appearance of the irradiated breast. No breast retraction and fibrosis were observed in any of the patients. Additionally, only 4 patients experienced grade 1 late toxicity (7.28%). None had grade 3 or higher late toxicity. Conclusion This is the first study to report the 10-year results of PBI after breast-conserving surgery in Chinese patients. Our study suggested that PBI had durable local control and maintained good cosmetic outcomes with minimal late toxicity at long term follow up for the early stage breast cancer patients.
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Affiliation(s)
- Yan Li
- Radiation Oncology, Lung Cancer Center and State Key Laboratory of Biotherapy West China Hospital, Sichuan University, Chengdu, China
| | - Lin Shui
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaodong Wang
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yu Sun
- Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Renming Zhong
- Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Pixian Shui
- School of Pharmacy, Southwest Medical University, Luzhou, China
| | - Nianyong Chen
- Radiation Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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Pasalic D, Strom EA, Allen PK, Williamson TD, Poenisch F, Amos RA, Woodward WA, Stauder MC, Shaitelman SF, Smith BD, Perkins GH, Tereffe W, Hoffman KE. Proton Accelerated Partial Breast Irradiation: Clinical Outcomes at a Planned Interim Analysis of a Prospective Phase 2 Trial. Int J Radiat Oncol Biol Phys 2020; 109:441-448. [PMID: 32946965 DOI: 10.1016/j.ijrobp.2020.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To perform a planned interim analysis of acute (within 12 months) and late (after 12 months) toxicities and cosmetic outcomes after proton accelerated partial breast irradiation (APBI). METHODS AND MATERIALS A total of 100 patients with pTis or pT1-2 N0 (≤3cm) breast cancer status after segmental mastectomy were enrolled in a single-arm phase 2 study from 2010 to 2019. The clinically determined postlumpectomy target volume, including tumor bed surgical clips and operative-cavity soft-tissue changes seen on imaging plus a radial clinical expansion, was irradiated with passively scattered proton APBI (34 Gy in 10 fractions delivered twice daily with a minimum 6-hour interfraction interval). Patients were evaluated at protocol-specific time intervals for recurrence, physician reports of cosmetic outcomes and toxicities, and patient reports of cosmetic outcomes and satisfaction with the treatment or experience. RESULTS Median follow-up was 24 months (interquartile range [IQR], 12-43 months). Local control and overall survival were 100% at 12 and 24 months. There were no acute or late toxicities of grade 3 or higher; no patients experienced fat necrosis, fibrosis, infection, or breast shrinkage. Excellent or good cosmesis at 12 months was reported by 91% of patients and 94% of physicians; at the most recent follow-up, these were 94% and 87%, respectively. The most commonly reported late cosmetic effect was telangiectasis (17%). The total patient satisfaction rate for treatment and results at 12 and 24 months was 96% and 100%, respectively. Patients' mean time away from work was 5 days (IQR, 2-5 days), and the median out-of-pocket cost was $700 (IQR, $100-$1600). The mean left-sided heart dose was 2 cGy (range, 0.2-75 cGy), and the mean ipsilateral lung dose was 19 cGy (range, 0.2-164 cGy). CONCLUSIONS Proton APBI is a maturing treatment option with high local control, favorable intermediate-term cosmesis, high treatment satisfaction, low treatment burden, and exceptional heart and lung sparing.
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Affiliation(s)
- Dario Pasalic
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Eric A Strom
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas.
| | - Pamela K Allen
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Tyler D Williamson
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Falk Poenisch
- Department of Radiation Physics, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Richard A Amos
- Department of Radiation Physics, MD Anderson Cancer Center, The University of Texas, Houston, Texas; Department of Proton and Advanced Radiation Therapy Group, Department of Medical Physics & Biomedical Engineering, University College London, London, United Kingdom
| | - Wendy A Woodward
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Michael C Stauder
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - George H Perkins
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Welela Tereffe
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Karen E Hoffman
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
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Wang K, Yee C, Tam S, Drost L, Chan S, Zaki P, Rico V, Ariello K, Dasios M, Lam H, DeAngelis C, Chow E. Prevalence of pain in patients with breast cancer post-treatment: A systematic review. Breast 2018; 42:113-127. [DOI: 10.1016/j.breast.2018.08.105] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/08/2018] [Accepted: 08/27/2018] [Indexed: 12/12/2022] Open
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Bennion NR, Baine M, Granatowicz A, Wahl AO. Accelerated partial breast radiotherapy: a review of the literature and future directions. Gland Surg 2018; 7:596-610. [PMID: 30687631 DOI: 10.21037/gs.2018.11.05] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Breast conservation therapy exemplifies the tailoring of medicine in the care of patients with cancer. Akin to improvements in surgical approaches, accelerated partial breast irradiation (APBI) tailors the treatment volume and duration to the needs of well selected patients. Here, we examine the evidence supporting APBI as well as the lessons in patient selection, dose and delivery techniques. Examination of historical techniques and their associated outcomes will support more correct patient selection and treatment delivery in an era where we await the reports of several large prospective trials.
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Affiliation(s)
- Nathan R Bennion
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael Baine
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Andrew O Wahl
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
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The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation. Brachytherapy 2018; 17:154-170. [DOI: 10.1016/j.brachy.2017.09.004] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 12/29/2022]
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Sayan M, Hard D, Wilson K, Nelson C, Gagne H, Rubin D, Heimann R. Long-term cosmesis following a novel schedule of accelerated partial breast radiation in selected early stage breast cancer: result of a prospective clinical trial. Radiat Oncol J 2017; 35:325-331. [PMID: 29207864 PMCID: PMC5769880 DOI: 10.3857/roj.2017.00171] [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: 04/03/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 11/03/2022] Open
Abstract
PURPOSE There is controversy regarding the cosmetic outcome after accelerated partial breast radiation (APBR). We report the cosmetic outcome from a single-arm prospective clinical trial of APBR delivered using intensity-modulated radiation therapy (IMRT) in elderly patients with stage I breast cancer (BC), using a novel fractionation schedule. MATERIALS AND METHODS Forty-two patients aged ≥65, with Stage I BC who underwent breast-conserving surgery were enrolled in a phase I/II study evaluating a 2-week course of APBR. Thirty eligible patients received 40 Gy in 4 Gy daily fractions. Cosmetic outcome was assessed subjectively by physician/patient and objectively by using a computer program (BCCT.core) before APBR, during, and after completion of the treatment. RESULTS The median age was 72 years, the median tumor size was 0.8 cm, and the median follow-up was 50.5 months. The 5-year locoregional control in this cohort was 97% and overall survival 87%. At the last follow-up, patients and physicians rated cosmesis as 'excellent' or 'good' in 100% and 91 %, respectively. The BCCT.core program scored the cosmesis as 'excellent' or 'good' in 87% of the patients at baseline and 81% at the last follow-up. The median V50 (20 Gy) of the whole breast volume (WBV) was 37.2%, with the median WBV V100 (40 Gy) of 10.9%. CONCLUSION An excellent rate of tumor control was observed in this prospective trial. By using multiple assessment techniques, we are showing acceptable cosmesis, supporting the use of IMRT planned APBR with daily schedule in elderly patients with early stage BC.
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Affiliation(s)
- Mutlay Sayan
- Department of Radiation Oncology, University of Vermont Medical Center, Burlington, VT, USA
| | - Daphne Hard
- Department of Radiation Oncology, University of Vermont Medical Center, Burlington, VT, USA
| | - Karen Wilson
- University of Vermont Cancer Center, Burlington, VT, USA
| | - Carl Nelson
- Department of Radiation Oncology, University of Vermont Medical Center, Burlington, VT, USA
| | - Havaleh Gagne
- Department of Radiation Oncology, University of Vermont Medical Center, Burlington, VT, USA
| | - Deborah Rubin
- Department of Radiation Oncology, University of Vermont Medical Center, Burlington, VT, USA
| | - Ruth Heimann
- Department of Radiation Oncology, University of Vermont Medical Center, Burlington, VT, USA
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Correa C, Harris EE, Leonardi MC, Smith BD, Taghian AG, Thompson AM, White J, Harris JR. Accelerated Partial Breast Irradiation: Executive summary for the update of an ASTRO Evidence-Based Consensus Statement. Pract Radiat Oncol 2016; 7:73-79. [PMID: 27866865 DOI: 10.1016/j.prro.2016.09.007] [Citation(s) in RCA: 450] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 09/12/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To update the accelerated partial breast irradiation Consensus Statement published in 2009 and provide guidance on use of intraoperative radiation therapy (IORT) for partial breast irradiation in early-stage breast cancer, based on published evidence complemented by expert opinion. METHODS AND MATERIALS A systematic PubMed search using the same terms as the original Consensus Statement yielded 419 articles; 44 articles were selected. The authors synthesized the published evidence and, through a series of conference calls and e-mails, reached consensus regarding the recommendations. RESULTS The new recommendations include lowering the age in the "suitability group" from 60 to 50 years and in the "cautionary group" to 40 years for patients who meet all other elements of suitability (Table 1). Patients with low-risk ductal carcinoma in situ, as per Radiation Therapy Oncology Group 9804 criteria, were categorized in the "suitable" group. The task force agreed to maintain the current criteria based on margin status. Recommendations for the use of IORT for breast cancer patients include: counseling patients regarding the higher risk of ipsilateral breast tumor recurrence with IORT compared with whole breast irradiation; the need for prospective monitoring of long-term local control and toxicity with low-energy radiograph IORT given limited follow-up; and restriction of IORT to women with invasive cancer considered "suitable." CONCLUSION These recommendations will provide updated clinical guidance regarding use of accelerated partial breast irradiation for radiation oncologists and other specialists participating in the care of breast cancer patients.
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Affiliation(s)
- Candace Correa
- Department of Radiation Oncology, Faxton St. Luke's Healthcare, Utica, New York
| | - Eleanor E Harris
- Department of Radiation Oncology, East Carolina University, Greenville, North Carolina
| | | | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alastair M Thompson
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Julia White
- Department of Radiation Oncology, Ohio State University Cancer Center, Columbus, Ohio
| | - Jay R Harris
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
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Rebekah Shin JH, McGuffin M, Pignol JP, Keller B, D'Alimonte L. Permanent Breast Seed Implant for Early-stage Breast Cancer: Impact of Primary Tumour Location on the Overall Cosmetic Outcome. J Med Imaging Radiat Sci 2015; 46:85-89. [PMID: 31052071 DOI: 10.1016/j.jmir.2014.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 11/21/2014] [Accepted: 11/24/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Permanent breast seed implants (PBSIs) have been introduced as an alternative to whole breast irradiation with equivalent rates of tumour control but fewer associated morbidities. However, there is some suggestion that tumour location has an effect on cosmesis in patients having PBSI. Therefore, the aim of the present study was to determine whether tumour location can predict long-term cosmesis. METHODS A retrospective chart review was conducted from May 2004 to November 2009. Tumour location was categorized according to breast quadrant. Late cosmesis was scored as the presence or absence of induration, telangiectasia, and pigmentation change at 3 years after implant. Acute toxicities were also recorded as the presence or absence of induration, dryness, and radiation dermatitis at 8 weeks after implant. Additionally, the tumour size, depth of the seroma, depth of 100% isodose, and tissue thickness were collected. Descriptive statistics and Fisher exact tests were used to analyze the relationship between tumour location and both acute and late morbidities. Individual t tests were used to determine whether tumour size, depth, and tissue thickness were predictive of acute and long-term side effects. RESULTS Of the 70 patients included in the study, 17 (24%) had tumours located in the upper inner quadrant (UIQ), 37 (53%) had tumours located in the upper outer quadrant, and 8 (11%) had tumours located in each of the remaining two quadrants. In general, 35% (6/17) of patients with tumours in the UIQ experienced long-term side effects compared with 34% (18/53) of patients with tumours in any other quadrant (P = .7617). Also, 82% (14/17) of patients with tumours in the UIQ experienced acute side effects compared with only 51% (27/53) of patients with tumours in any other quadrant (P = .0259). There was a significant effect of both primary tumour size (P = .004) and the depth of the 100% isodose (P = .028) on overall long-term cosmesis, but there was no significant relationship between physical factors and overall acute side effects. CONCLUSIONS Patients with tumours in the UIQ experience acute side effects more frequently than patients with tumours in any other quadrant. However, this trend is not as obvious for long-term cosmesis. Instead, tumour size and depth may be more useful when considering late effects.
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Affiliation(s)
| | - Merrylee McGuffin
- Department of Radiation Therapy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Brian Keller
- University of Toronto, Toronto, Ontario, Canada; Department of Medical Physics, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laura D'Alimonte
- University of Toronto, Toronto, Ontario, Canada; Department of Radiation Therapy, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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11
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Mellon EA, Sreeraman R, Gebhardt BJ, Mierzejewski A, Correa CR. Impact of radiation treatment parameters and adjuvant systemic therapy on cosmetic outcomes after accelerated partial breast irradiation using 3-dimensional conformal radiation therapy technique. Pract Radiat Oncol 2014; 4:e159-e166. [DOI: 10.1016/j.prro.2013.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 08/02/2013] [Accepted: 08/05/2013] [Indexed: 01/23/2023]
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12
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Liss AL, Ben-David MA, Jagsi R, Hayman JA, Griffith KA, Moran JM, Marsh RB, Pierce LJ. Decline of cosmetic outcomes following accelerated partial breast irradiation using intensity modulated radiation therapy: results of a single-institution prospective clinical trial. Int J Radiat Oncol Biol Phys 2014; 89:96-102. [PMID: 24613813 DOI: 10.1016/j.ijrobp.2014.01.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/04/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE To report the final cosmetic results from a single-arm prospective clinical trial evaluating accelerated partial breast irradiation (APBI) using intensity modulated radiation therapy (IMRT) with active-breathing control (ABC). METHODS AND MATERIALS Women older than 40 with breast cancer stages 0-I who received breast-conserving surgery were enrolled in an institutional review board-approved prospective study evaluating APBI using IMRT administered with deep inspiration breath-hold. Patients received 38.5 Gy in 3.85-Gy fractions given twice daily over 5 consecutive days. The planning target volume was defined as the lumpectomy cavity with a 1.5-cm margin. Cosmesis was scored on a 4-category scale by the treating physician. Toxicity was scored according to National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 3.0). We report the cosmetic and toxicity results at a median follow-up of 5 years. RESULTS A total of 34 patients were enrolled. Two patients were excluded because of fair baseline cosmesis. The trial was terminated early because fair/poor cosmesis developed in 7 of 32 women at a median follow-up of 2.5 years. At a median follow-up of 5 years, further decline in the cosmetic outcome was observed in 5 women. Cosmesis at the time of last assessment was 43.3% excellent, 30% good, 20% fair, and 6.7% poor. Fibrosis according to CTCAE at last assessment was 3.3% grade 2 toxicity and 0% grade 3 toxicity. There was no correlation of CTCAE grade 2 or greater fibrosis with cosmesis. The 5-year rate of local control was 97% for all 34 patients initially enrolled. CONCLUSIONS In this prospective trial with 5-year median follow-up, we observed an excellent rate of tumor control using IMRT-planned APBI. Cosmetic outcomes, however, continued to decline, with 26.7% of women having a fair to poor cosmetic result. These results underscore the need for continued cosmetic assessment for patients treated with APBI by technique.
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MESH Headings
- Adult
- Aged
- Breast/pathology
- Breast/radiation effects
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Breath Holding
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Dose Fractionation, Radiation
- Early Termination of Clinical Trials
- Esthetics
- Female
- Fibrosis
- Follow-Up Studies
- Humans
- Middle Aged
- Movement
- Prospective Studies
- Radiation Injuries/pathology
- Radiotherapy, Intensity-Modulated/adverse effects
- Radiotherapy, Intensity-Modulated/methods
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Affiliation(s)
- Adam L Liss
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Merav A Ben-David
- Department of Radiation Oncology, The Sheba Medical Center, Ramat Gan, Israel
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Biostatistics Unit, University of Michigan, Ann Arbor, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Robin B Marsh
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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13
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Five-Year Outcomes, Cosmesis, and Toxicity With 3-Dimensional Conformal External Beam Radiation Therapy to Deliver Accelerated Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2013; 87:1051-7. [DOI: 10.1016/j.ijrobp.2013.08.046] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/12/2013] [Accepted: 08/27/2013] [Indexed: 01/29/2023]
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14
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Shah C, Wilkinson JB, Lanni T, Jawad M, Wobb J, Fowler A, Wallace M, Chen P, Grills IS, Vicini F. Five-Year Outcomes and Toxicities Using 3-Dimensional Conformal External Beam Radiation Therapy to Deliver Accelerated Partial Breast Irradiation. Clin Breast Cancer 2013; 13:206-11. [DOI: 10.1016/j.clbc.2012.09.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 09/20/2012] [Accepted: 09/26/2012] [Indexed: 01/30/2023]
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15
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Chafe S, Moughan J, McCormick B, Wong J, Pass H, Rabinovitch R, Arthur DW, Petersen I, White J, Vicini FA. Late toxicity and patient self-assessment of breast appearance/satisfaction on RTOG 0319: a phase 2 trial of 3-dimensional conformal radiation therapy-accelerated partial breast irradiation following lumpectomy for stages I and II breast cancer. Int J Radiat Oncol Biol Phys 2013; 86:854-9. [PMID: 23726000 DOI: 10.1016/j.ijrobp.2013.04.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 03/06/2013] [Accepted: 04/02/2013] [Indexed: 12/28/2022]
Abstract
PURPOSE Late toxicities and cosmetic analyses of patients treated with accelerated partial breast irradiation (APBI) on RTOG 0319 are presented. METHODS AND MATERIALS Patients with stages I to II breast cancer ≤3 cm, negative margins, and ≤3 positive nodes were eligible. Patients received three-dimensional conformal external beam radiation therapy (3D-CRT; 38.5 Gy in 10 fractions twice daily over 5 days). Toxicity and cosmesis were assessed by the patient (P), the radiation oncologist (RO), and the surgical oncologist (SO) at 3, 6, and 12 months from the completion of treatment and then annually. National Cancer Institute Common Terminology Criteria for Adverse Events, version 3.0, was used to grade toxicity. RESULTS Fifty-two patients were evaluable. Median follow-up was 5.3 years (range, 1.7-6.4 years). Eighty-two percent of patients rated their cosmesis as good/excellent at 1 year, with rates of 64% at 3 years. At 3 years, 31 patients were satisfied with the treatment, 5 were not satisfied but would choose 3D-CRT again, and none would choose standard radiation therapy. The worst adverse event (AE) per patient reported as definitely, probably, or possibly related to radiation therapy was 36.5% grade 1, 50% grade 2, and 5.8% grade 3 events. Grade 3 AEs were all skin or musculoskeletal-related. Treatment-related factors were evaluated to potentially establish an association with observed toxicity. Surgical bed volume, target volume, the number of beams used, and the use of bolus were not associated with late cosmesis. CONCLUSIONS Most patients enrolled in RTOG 0319 were satisfied with their treatment, and all would choose to have the 3D-CRT APBI again.
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MESH Headings
- Breast/pathology
- Breast/radiation effects
- Breast Neoplasms/pathology
- Breast Neoplasms/psychology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/psychology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Diagnostic Self Evaluation
- Dose Fractionation, Radiation
- Esthetics/psychology
- Female
- Humans
- Mastectomy, Segmental
- Neoplasm Staging
- Organ Size/radiation effects
- Patient Satisfaction
- Radiation Injuries/pathology
- Radiation Injuries/psychology
- Radiotherapy, Conformal/adverse effects
- Radiotherapy, Conformal/psychology
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Affiliation(s)
- Susan Chafe
- Department of Radiation Oncology, Cross Cancer Institute-University of Alberta, Edmonton, Alberta, Canada.
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16
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Barry M, Ho A, Morrow M. The evolving role of partial breast irradiation in early-stage breast cancer. Ann Surg Oncol 2013; 20:2534-40. [PMID: 23463089 DOI: 10.1245/s10434-013-2923-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Indexed: 01/24/2023]
Abstract
Whole breast irradiation (WBI) over 5-7 weeks has long been considered standard adjuvant treatment after breast-conserving surgery. Recently the concept of irradiating the whole breast has been challenged by accelerated partial breast irradiation (APBI), which exclusively targets the lumpectomy site plus margin. We review the evidence supporting APBI from modern clinical trials, the pros and cons of various APBI techniques, and the controversies regarding the applicability of APBI to specific patient groups.
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Affiliation(s)
- Mitchel Barry
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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17
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Bourgier C, Acevedo-Henao C, Dunant A, Rossier C, Levy A, El Nemr M, Dumas I, Delaloge S, Mathieu MC, Garbay JR, Taghian A, Marsiglia H. Higher toxicity with 42 Gy in 10 fractions as a total dose for 3D-conformal accelerated partial breast irradiation: results from a dose escalation phase II trial. Radiat Oncol 2012; 7:141. [PMID: 22913640 PMCID: PMC3502482 DOI: 10.1186/1748-717x-7-141] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 07/13/2012] [Indexed: 11/25/2022] Open
Abstract
Objective Recent recommendations regarding indications of accelerated partial breast irradiation (APBI) have been put forward for selected breast cancer (BC) patients. However, some treatment planning parameters, such as total dose, are not yet well defined. The Institut Gustave Roussy has initiated a dose escalation trial at the 40 Gy/10 fractions/5 days and at a further step of total dose (TD) of 42 Gy/10 fractions/ 5 days. Here, we report early results of the latest step compared with the 40 Gy dose level. Methods and materials From October 2007 to March 2010, a total of 48 pT1N0 BC patients were enrolled within this clinical trial: 17 patients at a TD of 42 Gy/10f/5d and 31 at a TD of 40 Gy/10f/5d. Median follow-up was 19 months (min-max, 12–26). All the patients were treated by APBI using a technique with 2 minitangents and an “enface” electrons delivering 20% of the total dose. Toxicities were systematically assessed at 1; 2; 6 months and then every 6 months. Results Patients’ recruitment of 42 Gy step was ended owing to persistent grade 3 toxicity 6 months after APBI completion (n = 1). Early toxicities were statistically higher after a total dose of 42 Gy regarding grade ≥2 dry (p = 0.01) and moist (p = 0.05) skin desquamation. Breast pain was also statistically higher in the 42 Gy step compared to 40 Gy step (p = 0.02). Other late toxicities (grade ≥2 fibrosis and telangectasia) were not statistically different between 42 Gy and 40 Gy. Conclusions Early toxicities were more severe and higher rates of late toxicities were observed after 42 Gy/10 fractions/5 days when compared to 40 Gy/10 fractions/5 days. This data suggest that 40 Gy/10 fractions/ 5 days could potentially be the maximum tolerance for PBI although longer follow-up is warranted to better assess late toxicities.
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Affiliation(s)
- Celine Bourgier
- Department of Radiation Oncology, Institut Gustave Roussy, 114 rue Edouard Vaillant, 94 805, Villejuif, France.
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18
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Mukesh M, Harris E, Jena R, Evans P, Coles C. Relationship between irradiated breast volume and late normal tissue complications: a systematic review. Radiother Oncol 2012; 104:1-10. [PMID: 22682540 DOI: 10.1016/j.radonc.2012.04.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 03/29/2012] [Accepted: 04/30/2012] [Indexed: 12/25/2022]
Abstract
The concept of radiation dose-volume effect has been exploited in breast cancer as boost treatment for high risk patients and more recently in trials of Partial Breast Irradiation for low risk patients. However, there appears to be paucity of published data on the dose-volume effect of irradiation on breast tissue including the recently published report on Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC). This systematic review looks at the current literature for relationship between irradiated breast volume and normal tissue complications and introduces the concept of dose modulation.
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Affiliation(s)
- Mukesh Mukesh
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK.
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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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Azoury F, Heymann S, Acevedo C, Spielmann M, Vielh P, Garbay JR, Taghian AG, Marsiglia H, Bourgier C. Phase II trial of 3D-conformal accelerated partial breast irradiation: Lessons learned from patients and physicians’ evaluation. Radiother Oncol 2012; 103:193-8. [DOI: 10.1016/j.radonc.2012.03.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 03/09/2012] [Accepted: 03/20/2012] [Indexed: 11/27/2022]
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21
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Pinnarò P, Arcangeli S, Giordano C, Arcangeli G, Impiombato FA, Pinzi V, Iaccarino G, Soriani A, Landoni V, Strigari L. Toxicity and cosmesis outcomes after single fraction partial breast irradiation in early stage breast cancer. Radiat Oncol 2011; 6:155. [PMID: 22079051 PMCID: PMC3229442 DOI: 10.1186/1748-717x-6-155] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 11/11/2011] [Indexed: 01/30/2023] Open
Abstract
Background To report the clinical outcome after a Single Shot 3D-CRT PBI (SSPBI) in breast cancer patients after conservative surgery (ClinicalTrials.gov Identifier: NCT01316328). Methods A dose of 18Gy (in the first 4 patients) and 21Gy (in the remaining 60 patients) was prescribed in a single session and delivered to the index area (i.e. the area of breast including the primary tumor bed and the surrounding tissue) using 3D-CRT with patients in prone position. Acute and late toxicity was assessed using the National Cancer Institute's CTC for Adverse Events. Cosmesis was defined based on modified Harvard criteria. Differences between dosimetric or clinical parameters of patients with/without G2 or more late toxicity or unsatisfactory (poor or fair) cosmetic outcome were evaluated with the Mann-Whitney test. Odds ratios and 95% confidence interval were calculated for cosmesis and fibrosis. Univariate and multivariate analyses(UVA/MVA) were used to determine covariates associated with an increase in fibrosis or fat necrosis rate. Results Sixty four patients were enrolled. With a median follow-up of 3 years, G2 and G3 subcutaneous fibrosis was detected in 20(31%) and in 8(13%) patients, and ≥G2 fat necrosis was observed in 2(3%) patients. Good to excellent, fair and poor cosmesis was observed in 38(59%), 23(36%) and 3(5%) patients, respectively. Based on UVA, the breast volume receiving more than 21Gy (V21Gy) was found to be a predictor of the ≥G1 or ≥G2 fibrosis/fat necrosis. Based on MVA, V21Gy was confirmed as a predictor for ≥G1 fibrosis/fat necrosis, the results correlated as a trend for ≥G2. Cosmesis was correlated with whole breast (WB) mean dose (p = 0.030). Conclusion Our choice of a single dose of 21Gy significantly increased the treatment related toxicity. However, this should not discourage novel SSPBI approaches with lower equivalent doses.
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Affiliation(s)
- Paola Pinnarò
- Department of Radiation Oncology, Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Rome, Italy
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