1
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Smith DR, Formenti SC. Treatment deescalation for older women with favorable breast cancers: patient values and shared decision making. J Natl Cancer Inst 2025:djaf001. [PMID: 40232739 DOI: 10.1093/jnci/djaf001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2024] [Revised: 12/18/2024] [Accepted: 12/19/2024] [Indexed: 04/16/2025] Open
Affiliation(s)
- Deborah R Smith
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY 10065, United States
| | - Silvia C Formenti
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY 10065, United States
- Department of Medicine, Weill Cornell Medicine, New York, NY 10065, United States
- Meyer Cancer Center, Weill Cornell Medicine, New York, NY 10065, United States
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Zabrocka E, Roberson JD, Noldner C, Kim J, Patel R, Ryu S, Stessin A. Stereotactic body radiation therapy (SBRT) for the treatment of primary breast cancer in patients not undergoing surgery. Adv Med Sci 2024; 69:29-35. [PMID: 38306916 DOI: 10.1016/j.advms.2024.01.002] [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: 03/29/2023] [Revised: 09/26/2023] [Accepted: 01/18/2024] [Indexed: 02/04/2024]
Abstract
PURPOSE The purpose was to explore the role of stereotactic body radiation therapy (SBRT) in providing local control (LC) for primary breast cancer in patients unable to undergo surgery. MATERIALS/METHODS Between 2015 and 2019, 13 non-surgical candidates with 14 lesions were treated with SBRT for primary breast cancer. In 4 cases, SBRT was used after whole breast radiation therapy (WBRT; 40-50 Gy/20-25 fractions). SBRT dose was 30-40 Gy in 5 fractions for patients treated with SBRT alone and 25-32 Gy in 4-5 fractions for those treated with SBRT + WBRT. LC and overall survival (OS) were estimated using Kaplan-Meier curves. Response was also assessed using RECIST guidelines. RESULTS Median follow-up was 32 (range: 3.4-70.4) months. Imaging at median 2.2 (0.6-8.1) months post-SBRT showed median 43.2 % (range: 2-100 %) decrease in the largest diameter and median 68.7 % (range: 27.9-100 %) SUV reduction. There were 3 cases of local progression at 8.7-10.6 months. Estimated LC was 100 % at 6 months and 71.6 % at 12, 24 and 36 months. Estimated median OS was 100 % at 6 months, 76.9 % at 12 months, and 61.5 % at 24 and 36 months. Acute toxicity (n = 13; 92.9 %) included grade (G)1 (n = 8), G2 (n = 4), and G4 (necrosis; n = 1). Late toxicity included G2 edema (n = 1) and G4 necrosis (n = 2, including 1 consequential late effect). Only patients treated with SBRT + WBRT experienced acute/late G4 toxicity, managed with resection or steroids. CONCLUSIONS SBRT to primary breast cancer resulted in good LC in non-surgical/metastatic patients. Although necrosis (n = 2) occurred in the SBRT + WBRT group, it was successfully salvaged.
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Affiliation(s)
- Ewa Zabrocka
- Department of Radiation Oncology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - John D Roberson
- Southeast Radiation Oncology Group, Charlotte, NC, USA; Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Collin Noldner
- Department of Radiation Oncology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Jinkoo Kim
- Department of Radiation Oncology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Rushil Patel
- Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Samuel Ryu
- Department of Radiation Oncology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Alexander Stessin
- Department of Radiation Oncology, Stony Brook University Hospital, Stony Brook, NY, USA.
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3
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Zabrocka E, Polce S, Roberson JD, Wu J, Cohen J, Baer L, Stopeck A, Ryu S, Stessin A. Utility of Stereotactic Body Radiation Therapy in Establishing Local Control for Patients With Invasive Breast Cancer Not Undergoing Definitive Surgery. Int J Radiat Oncol Biol Phys 2024; 118:436-442. [PMID: 37793576 DOI: 10.1016/j.ijrobp.2023.08.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/11/2023] [Accepted: 08/21/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE Surgery is the backbone of breast cancer (BC) treatment. For patients who cannot undergo surgery, improving local control (LC) of the primary tumor is paramount. To that end, this study explored the role of stereotactic body radiation therapy (SBRT). METHODS AND MATERIALS Between 2015 and 2022, 21 nonsurgical candidates (10 metastatic, 11 stage IA-IIIC) received 23 SBRT courses to primary BC. Seven were analyzed retrospectively; 15 are currently enrolled in a prospective study. SBRT (40 Gy/5 fractions) was delivered every other day. Follow-up imaging was reviewed. Acute (≤3 months) and late toxicities were evaluated using Common Terminology Criteria for Adverse Events, version 5. LC and overall survival (OS) were estimated using Kaplan-Meier curves. RESULTS Median age was 78.4 years (45.9-97.3). Median follow-up was 14.7 months (3.3-70.3). Median pre-SBRT index lesion size was 3.1 cm (0.5-14.5) and planning treatment volume was 32.4 cc (11.5-522.4). Initial posttreatment imaging performed at a median 4.0 months (0.6-11.9) post-SBRT demonstrated median decrease in index lesion size of 20.8% (0%-100%); SUV reduction of 65.2% (20.8%-100%). Second follow-up scans at a median 7.8 months post-SBRT showed 62% (0%-100%) and 88% (33.3%-100%) median reduction in tumor size and SUV, respectively, compared with pre-SBRT values. The estimated LC rate was 100% at 6 months and 93.3% at 12, 24, and 36 months. Local progression occurred in 1 case 9.5 months after SBRT, after an initial response. Regional progression occurred in 4 cases (17.4%) at a median 18.6 months (5.2-22.7) post-SBRT. Six patients (35.3%) developed distant progression at a median 2.7 months (0.9-16.2). The estimated OS was 85.7% at 6 months, 69.6% at 12 months, and 63.8% at 24 and 36 months. The rates of acute toxicity were G1: 47.8%, G2: 4.3%, G3: 8.7%, and G4: 0%. CONCLUSIONS Definitive SBRT for primary BC resulted in good LC in nonsurgical patients and was well-tolerated. Considering the pattern of progression, additional approaches to improve regional/distant control should be investigated.
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Affiliation(s)
- Ewa Zabrocka
- Department of Radiation Oncology, Stony Brook University, Stony Brook, NY.
| | - Simran Polce
- Renaissance School of Medicine, Stony Brook, New York.
| | - John D Roberson
- Southeast Radiation Oncology Group, Charlotte, North Carolina; Levine Cancer Institute, Atrium Health, Charlotte, North Carolina.
| | - Jieying Wu
- Department of Radiation Oncology, Stony Brook University, Stony Brook, NY.
| | - Jules Cohen
- Department of Medicine, Stony Brook University, Stony Brook, New York.
| | - Lea Baer
- Department of Medicine, Stony Brook University, Stony Brook, New York.
| | - Alison Stopeck
- Department of Medicine, Stony Brook University, Stony Brook, New York.
| | - Samuel Ryu
- Department of Radiation Oncology, Stony Brook University, Stony Brook, NY.
| | - Alexander Stessin
- Department of Radiation Oncology, Stony Brook University, Stony Brook, NY.
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4
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Ocanto A, Torres L, Montijano M, Rincón D, Fernández C, Sevilla B, Gonsalves D, Teja M, Guijarro M, Glaría L, Hernánz R, Zafra-Martin J, Sanmamed N, Kishan A, Alongi F, Moghanaki D, Nagar H, Couñago F. MR-LINAC, a New Partner in Radiation Oncology: Current Landscape. Cancers (Basel) 2024; 16:270. [PMID: 38254760 PMCID: PMC10813892 DOI: 10.3390/cancers16020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Technological advances in radiation oncology are oriented towards improving treatment precision and tumor control. Among these advances, magnetic-resonance-image-guided radiation therapy (MRgRT) stands out, with technological advances to deliver targeted treatments adapted to a tumor's anatomy on the day while minimizing incidental exposure to organs at risk, offering an unprecedented therapeutic advantage compared to X-ray-based IGRT delivery systems. This new technology changes the traditional workflow in radiation oncology and requires an evolution in team coordination to administer more precise treatments. Once implemented, it paves the way for newer indication for radiation therapy to safely deliver higher doses than ever before, with better preservation of healthy tissues to optimize patient outcomes. In this narrative review, we assess the technical aspects of the novel linear accelerators that can deliver MRgRT and summarize the available published experience to date, focusing on oncological results and future challenges.
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Affiliation(s)
- Abrahams Ocanto
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Lisselott Torres
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Miguel Montijano
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Diego Rincón
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Castalia Fernández
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Beatriz Sevilla
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Daniela Gonsalves
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Macarena Teja
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Marcos Guijarro
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
| | - Luis Glaría
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
| | - Raúl Hernánz
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
| | - Juan Zafra-Martin
- Group of Translational Research in Cancer Immunotherapy, Centro de Investigaciones Médico-Sanitarias (CIMES), Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain;
- Department of Radiation Oncology, Hospital Universitario Virgen de la Victoria, 29010 Málaga, Spain
| | - Noelia Sanmamed
- Department of Radiation Oncology, Hospital Universitario Clínico San Carlos, 28040 Madrid, Spain;
| | - Amar Kishan
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, USA;
| | - Filippo Alongi
- Advanced Radiation Oncology Department, Cancer Care Center, IRCCS Sacro Cuore Don Calabria Hospital, 37024 Negrar, Italy;
- University of Brescia, 25121 Brescia, Italy
| | - Drew Moghanaki
- UCLA Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA 90095, USA;
| | - Himanshu Nagar
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY 10065, USA;
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario San Francisco de Asís, GenesisCare, 28002 Madrid, Spain; (L.T.); (M.M.); (D.R.); (C.F.); (B.S.); (D.G.); (M.T.); (M.G.); (L.G.); (R.H.); (F.C.)
- Department of Radiation Oncology, Hospital Universitario Vithas La Milagrosa, GenesisCare, 28010 Madrid, Spain
- GenesisCare, 28043 Madrid, Spain
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Yu CX. Radiotherapy of early-stage breast cancer. PRECISION RADIATION ONCOLOGY 2023; 7:67-79. [PMID: 40336616 PMCID: PMC11935132 DOI: 10.1002/pro6.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 01/30/2023] Open
Abstract
Breast cancer is the most prevalent disease for women. With advances in breast cancer screening, most breast cancers are now diagnosed in the early stages. With knowledge of different subtypes and their behavior, breast cancer treatment has become more individualized. Radiation therapy as one of the mainstays of breast cancer treatment has also been evolving. This review attempts to provide a summary of the most influential clinical studies that have driven the technological advances in radiation therapy for early-stage breast cancer.
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Affiliation(s)
- Cedric X. Yu
- Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
- Xcision Medical SystemsColumbiaMarylandUSA
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6
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Early effectiveness and toxicity outcomes of reirradiation after breast conserving surgery for recurrent or new primary breast cancer. Breast Cancer Res Treat 2023; 198:43-51. [PMID: 36604352 DOI: 10.1007/s10549-022-06853-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/28/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Breast reirradiation (reRT) after breast conserving surgery (BCS) has emerged as a viable alternative to mastectomy for women presenting with recurrent or new primary breast cancer. There are limited data on safety of different fractionation regimens. This study reports safety and efficacy among women treated with repeat BCS and reRT. METHODS AND MATERIALS Patients who underwent repeat BCS followed by RT from 2015 to 2021 at 2 institutions were analyzed. Univariate logistic regression models were used to identify predictors of acute and late toxicities. Kaplan-Meier estimates were used to evaluate overall survival (OS), distant metastasis-free survival (DMFS) and locoregional recurrence-free survival (LR-RFS). RESULTS Sixty-six patients were reviewed with median follow-up of 16 months (range: 3-60 months). At time of first recurrence, 41% had invasive carcinoma with a ductal carcinoma in situ (DCIS) component, 41% had invasive carcinoma alone and 18% had DCIS alone. All were clinically node negative. For the reirradiation course, 95% received partial breast irradiation (PBI) (57.5% with 1.5 Gy BID; 27% with 1.8 Gy daily; 10.5% with hypofractionation), and 5% received whole breast irradiation (1.8-2 Gy/fx), all of whom had received PBI for initial course. One patient experienced grade 3 fibrosis, and one patient experienced grade 3 telangiectasia. None had grade 4 or higher late adverse events. We found no association between the fractionation of the second course of RT or the cumulative dose (measured as EQD2) with acute or late toxicity. At 2 years, OS was 100%, DMFS was 91.6%, and LR-RFS was 100%. CONCLUSION In this series of patients with recurrent or new primary breast cancer, a second breast conservation surgery followed by reirradiation was effective with no local recurrences and an acceptable toxicity profile across a range of available fractionation regimens at a median follow up of 16 months. Longer follow up is required.
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Abeloos CH, Purswani JM, Galavis P, McCarthy A, Hitchen C, Choi JI, Gerber NK. Different Re-Irradiation Techniques after Breast-Conserving Surgery for Recurrent or New Primary Breast Cancer. Curr Oncol 2023; 30:1151-1163. [PMID: 36661737 PMCID: PMC9857440 DOI: 10.3390/curroncol30010088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/05/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Breast re-irradiation (reRT) after breast-conserving surgery (BCS) using external beam radiation is an increasingly used salvage approach for women presenting with recurrent or new primary breast cancer. However, radiation technique, dose and fractionation as well as eligibility criteria differ between studies. There is also limited data on efficacy and safety of external beam hypofractionation and accelerated partial-breast irradiation (APBI) regimens. This paper reviews existing retrospective and prospective data for breast reRT after BCS, APBI reRT outcomes and delivery at our institution and the need for a randomized controlled trial using shorter courses of radiation to better define patient selection for different reRT fractionation regimens.
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Affiliation(s)
| | - Juhi M. Purswani
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
| | - Paulina Galavis
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
| | - Allison McCarthy
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
| | - Christine Hitchen
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
| | - J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Naamit K. Gerber
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016, USA
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8
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Chang JS, Khan AJ. Accelerated Partial Breast Irradiation: Technological Advances and Current Challenges. Am J Clin Oncol 2023; 46:7-9. [PMID: 36562690 DOI: 10.1097/coc.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Accelerated partial breast irradiation is a mature, standard-of-care treatment option for many women with early-stage breast cancer. In this paper, we discuss technological challenges and advances in the delivery of accurate and reproducible accelerated partial breast irradiation.
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Affiliation(s)
- Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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9
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Ng J, Pennell R, Formenti SC. The initial experience of MRI-guided precision prone breast irradiation with daily adaptive planning in treating early stage breast cancer patients. Front Oncol 2022; 12:1048512. [PMID: 36505797 PMCID: PMC9728922 DOI: 10.3389/fonc.2022.1048512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/01/2022] [Indexed: 11/24/2022] Open
Abstract
Background A major challenge in breast radiotherapy is accurately targeting the surgical cavity volume. Application of the emerging MRI-guided radiotherapy (MRgRT) technique in breast radiotherapy may enable more accurate targeting and potentially reduce side effects associated with treatment. Purpose To study the feasibility of delivering MRI-guided partial breast radiotherapy or Precision Prone Irradiation (PPI) to treat DCIS and early stage breast cancer patients. Materials and methods Eleven patients with diagnosed DCIS or early stage breast cancer treated with lumpectomy underwent CT-based and MRI-based simulations and treatment planning in the prone position. MRI-guided radiotherapy was utilized to deliver partial breast irradiation. A customized adaptive plan was created for each delivered radiotherapy fraction and the cumulative doses to the target volumes and nearby organs at risk were determined. The CT-based and the MRI-guided radiotherapy plans were compared with respect to target volumes, target volume coverage, and dose to nearby organs. Results All patients receiving PPI successfully completed their treatments as planned. Clinical target volume (CTV) and planning target volume (PTV) dose coverage and organs-at-risk (OAR) dose constraints were met in all fractions planned and delivered and the MRI-guided clinical target volumes were smaller when compared to those of the CT-based partial breast radiotherapy plans for these eleven patients. Conclusions MRI-guided partial breast radiotherapy as a breast radiotherapy technology is feasible and is a potential high clinical impact application of MRgRT. PPI has the potential to improve the therapeutic index of breast radiotherapy by more accurately delivering radiation dose to the cavity target and decreasing toxicities associated with radiation to the surrounding normal tissues. Prospective clinical data and further technical refinements of this novel technology may broaden its clinical implementation.
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Galavis PE, Abeloos CH, Cheng PC, Hitchen C, McCarthy A, Purswani JM, Shah B, Taneja S, Gerber NK. Accelerated partial breast irradiation in early stage breast cancer. Front Oncol 2022; 12:1049704. [PMID: 36439449 PMCID: PMC9685302 DOI: 10.3389/fonc.2022.1049704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/25/2022] [Indexed: 12/10/2023] Open
Abstract
Accelerated partial breast irradiation (APBI) is increasingly used to treat select patients with early stage breast cancer. However, radiation technique, dose and fractionation as well as eligibility criteria differ between studies. This has led to controversy surrounding appropriate patients for APBI and an assessment of the toxicity and cosmetic outcomes of APBI as compared to whole breast irradiation (WBI). This paper reviews existing data for APBI, APBI delivery at our institution, and ongoing research to better define patient selection, treatment delivery, dosimetric considerations and toxicity outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Naamit K. Gerber
- Department of Radiation Oncology, New York University (NYU) Langone Health, School of Medicine, New York, NY, United States
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Takanen S, Pinnarò P, Farina I, Sperati F, Botti C, Vici P, Soriani A, Marucci L, Sanguineti G. Stereotactic partial breast irradiation in primary breast cancer: A comprehensive review of the current status and future directions. Front Oncol 2022; 12:953810. [PMID: 36313648 PMCID: PMC9606691 DOI: 10.3389/fonc.2022.953810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
In selected low-risk breast cancer patients, accelerated partial breast irradiation (APBI) may represent an alternative option to the whole breast irradiation to reduce the volume of irradiated breast and total treatment duration. In the last few years, preliminary data from clinical trials showed that stereotactic partial breast radiotherapy may have the advantage to be less invasive compared to other APBI techniques, with preliminary good results in terms of local toxicity and cosmesis: the use of magnetic resonance, fiducial markers in the tumor bed, and new breast devices support both a precise definition of the target and radiation planning.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021257856, identifier CRD42021257856.
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Affiliation(s)
- Silvia Takanen
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
- *Correspondence: Silvia Takanen, ; Ilaria Farina,
| | - Paola Pinnarò
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Ilaria Farina
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
- *Correspondence: Silvia Takanen, ; Ilaria Farina,
| | - Francesca Sperati
- Biostatistics, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Claudio Botti
- Surgery, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Patrizia Vici
- Phase IV Studies, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Antonella Soriani
- Physics, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Laura Marucci
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Sanguineti
- Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Regina Elena National Cancer Institute, Rome, Italy
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Xu H, Cheston SB, Gopal A, Zhang B, Chen S, Yu S, Hall A, Dudley S. A study of skin marker alignment using different diamond-shaped light fields for prone breast external-beam radiation therapy. J Appl Clin Med Phys 2022; 23:e13772. [PMID: 36029043 DOI: 10.1002/acm2.13772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 07/29/2022] [Accepted: 08/10/2022] [Indexed: 11/06/2022] Open
Abstract
For breast cancer patients treated in the prone position with tangential fields, a diamond-shaped light field (DSLF) can be used to align with corresponding skin markers for image-guided radiation therapy (IGRT). This study evaluates and compares the benefits of different DSLF setups. Seventy-one patients who underwent daily tangential kilovoltage (kV) IGRT were categorized retrospectively into four groups: (1) DSLF field size (FS) = 10 × 10 cm2 , gantry angle = 90° (right breast)/270° (left breast), with the same isocenter as treatment tangential beams; (2) same as group 1, except DSLF FS = 4 × 4 cm2 ; (3) DSLF FS = 4 × 4-6 × 8 cm2 , gantry angle = tangential treatment beam, off-isocenter so that the DSLF was at the approximate breast center; and (4) No-DSLF. We compared their total setup time (including any DSLF/marker-based alignment and IGRT) and relative kV-based couch shift corrections. For groups 1-3, DSLF-only dose distributions (excluding kV-based correction) were simulated by reversely shifting the couch positions from the computed tomography plans, which were assumed equivalent to the delivered dose when both DSLF and IGRT were used. For patient groups 1-4, the average daily setup time was 2.6, 2.5, 5.0, and 8.3 min, respectively. Their mean and standard deviations of daily kV-based couch shifts were 0.64 ± 0.4, 0.68 ± 0.3, 0.8 ± 0.6, and 1.0 ± 0.6 cm. The average target dose changes after excluding kV-IGRT for groups 1-3 were-0.2%, -0.1%, and +0.4%, respectively, whereas DSLF-1 was most efficient in sparing heart and chest wall, DSLF-2 had lowest lung Dmax ; and DSLF-3 maintained the highest target coverage at the cost of highest OAR dose. In general, the use of DSLF greatly reduces patient setup time and may result in smaller IGRT corrections. If IGRT is limited, different DSLF setups yield different target coverage and OAR dose sparing. Our findings will help DSLF setup optimization in the prone breast treatment setting.
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Affiliation(s)
- Huijun Xu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sally B Cheston
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Arun Gopal
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Baoshe Zhang
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Suhong Yu
- Department of Radiation Oncology, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - Andrea Hall
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sara Dudley
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Stereotactic Body Radiation in Breast Cancer — Definitive, Oligometastatic, and Beyond. CURRENT BREAST CANCER REPORTS 2022. [DOI: 10.1007/s12609-022-00447-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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14
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Vicini F, Broughman J, Halima A, Mayo Z, Obi E, Al-Hilli Z, Arthur D, Wazer D, Shah C. Delivery of Adjuvant Radiation in 5 Days or Less After Lumpectomy for Breast Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2021; 112:1090-1104. [PMID: 34921906 DOI: 10.1016/j.ijrobp.2021.11.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recent data have been published supporting the application of ultra-short radiation therapy (RT) regimens for women with early stage breast cancer following breast conserving surgery (BCS). What has remained controversial is whether and how to apply accelerated whole breast irradiation (AWBI) or accelerated partial breast irradiation (APBI) approaches in these patients, as well as the consideration of intraoperative RT (IORT) for this population. METHODS We performed a systematic review of the literature searching for randomized and prospective data published evaluating ultra-short RT delivered in 5-days or less with APBI, AWBI, or IORT. RESULTS We identified two randomized studies applying AWBI (n=5,011 patients) with 5 to 10 year follow up, which supported the use of ultra-short course AWBI (5 fractions in one week) as compared to hypofractionated WBI. We identified six randomized trials evaluating APBI (as compared to WBI) in 5 days or less (n= 8,415) with numerous (n=55) prospective studies as well, with the data supporting short course APBI as compared to WBI. Finally, we identified two randomized trials evaluating IORT; however, both trials demonstrated elevated rates of recurrence with IORT as compared to WBI. CONCLUSIONS The current body of data available for ultra-short adjuvant RT regimens delivered in 5-days or less after BCS overwhelming support their utilization. While data for both exists, APBI regimens have, by far, greater numbers of patients and longer follow-up as compared to AWBI. Also, given increased rates of recurrence seen with IORT with long-term follow-up, this should not be considered a standard approach at this time.
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Affiliation(s)
| | - James Broughman
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Halima
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zachary Mayo
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth Obi
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - David Wazer
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - Chirag Shah
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
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15
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Song YC, Sun GY, Fang H, Tang Y, Song YW, Hu C, Qi SN, Chen B, Jing H, Tang Y, Jin J, Liu YP, Lu NN, Li YX, Wang SL. Quality of Life After Partial or Whole-Breast Irradiation in Breast-Conserving Therapy for Low-Risk Breast Cancer: 1-Year Results of a Phase 2 Randomized Controlled Trial. Front Oncol 2021; 11:738318. [PMID: 34604082 PMCID: PMC8480312 DOI: 10.3389/fonc.2021.738318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/27/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose To report patients’ quality of life (QoL) at 1 year in a phase 2 randomized trial comparing partial breast irradiation (PBI) with whole-breast irradiation (WBI) after breast-conserving surgery (BCS) for breast cancer. Methods Women aged ≥ 45 years with low-risk breast cancer after BCS were randomly assigned (1:1) to receive PBI (40 Gy in 10 fractions over 2 weeks) or WBI (43.5 Gy in 15 fractions over 3 weeks). The primary endpoint—the incidence of toxicities of grade 2 or higher—will be reported when participants complete 5 years of follow-up. QoL was assessed at baseline (T0), at the end of radiotherapy (RT) (T1), 6 months (T2) and 1 year (T3) after RT by using the EORTC QLQ-C30 and QLQ-BR23 questionnaires. We calculated the scores for all QOL subscales and differences in mean scores were compared. This study was registered at ClinicalTrials.gov (NCT03583619). Results Between June 2017 and January 2019, 140 women were randomly assigned to receive PBI or WBI (n = 70 per group). Fifty-nine and 56 patients treated with PBI and WBI, respectively, were eligible for the QoL analysis. There were no significant differences in any subscale scores at T0, T1, T2, or T3 between the PBI and WBI arms. The scores for most QoL subscales that were influenced by RT recovered to a similar or better level relative to T0 scores within 1 year after RT, except for the scores of the dyspnea subscale. Longitudinal analysis showed that time since RT had a significant impact on physical functioning, role functioning, social functioning, fatigue, pain, dyspnea, financial difficulties, body image, and breast and arm symptoms. Conclusion PBI using the intensity-modulated RT affords QoL comparable to that provided by WBI. Most QoL subscale scores that were influenced by RT recovered to a similar or better level relative to baseline scores within 1 year after RT.
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Affiliation(s)
- Yu-Chun Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guang-Yi Sun
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Clinical Trials Center, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore MD, United States
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Leonard CE, Wang Y, Asmar L, Lei RY, Howell KT, Henkenberns PL, Johnson TK, Hobart TL, Tole SP, Kercher JM, Widner JL, Barke L, Kaske T, Carter DL. A prospective Phase III trial evaluating patient self-reported pain and cosmesis in accelerated partial breast irradiation utilizing 3-D versus intensity-modulated radiotherapy. Cancer Med 2021; 10:7089-7100. [PMID: 34469056 PMCID: PMC8525102 DOI: 10.1002/cam4.4242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/09/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose/Objective The primary objective is to examine patient self‐assessment of breast pain and cosmesis between three‐dimensional (3D‐CRT) versus intensity‐modulated radiotherapy (IMRT). The secondary objective is to evaluate any relationship of treatment planning conformality of both cohorts to patient‐assessed pain. Assessments were performed at interim 12, 24, 36, and 48 months with a final 5‐year assessment. Materials/Methods In total, 656 patients (3D‐CRT n = 328; IMRT n = 328) were randomly assigned to either IMRT or 3D‐CRT accelerated partial breast radiotherapy to 38.5 Gy in 10 BID 3.85 Gy fractions. Results Median follow‐up was 3 years. Multivariate analysis showed that pain severity significantly decreased from baseline to the 12‐month follow‐up visit (<0.001 for both 3D‐CRT and IMRT) in each cohort. There was significantly less pain at 2 (p = 0.002) and 3 years (0.045) in the IMRT arm versus the 3D‐CRT arm when compared to the baseline pain level. There was no difference in patient‐assessed cosmesis at any follow‐up point; however, although MD‐assessed cosmesis showed no difference from years 1 to 4, there was significantly better cosmesis for 3D‐CRT versus IMRT (p = 0.047) at 5 years. There was a significant correlation between a maximum pain score and an increase in the CI100 (indicating less conformity) in the IMRT cohort (p < 0.01) and in the IMRT subgroup when the CI100 was ≤0.37 cohort arm (p = 0.01). Conclusion In the analysis of our primary objective we found that at 2 years, IMRT resulted in more interval improvement in breast pain after baseline when compared to patients treated with 3D‐CRT planning. As seen in our secondary analysis, this may be due to the ability of IMRT to achieve higher conformality (as evidenced by lower CI values) resulting in less fibrosis. There were no differences in patient‐assessed cosmesis or MD‐assessed cosmesis for years 1–4; however, physician‐assessed 5‐year cosmesis was better with 3D‐CRT.
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Affiliation(s)
| | | | - Lina Asmar
- Linasmar Consulting, Houston, Texas, USA
| | - Rachel Y Lei
- Rocky Mountain Cancer Centers, Littleton, Colorado, USA
| | | | | | | | | | | | | | | | - Lora Barke
- Sally Jobe Diagnostic Breast Center, Greenwood Village, Colorado, USA
| | - Terese Kaske
- Sally Jobe Diagnostic Breast Center, Greenwood Village, Colorado, USA
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Verbelen H, Tjalma W, Dombrecht D, Gebruers N. Breast edema, from diagnosis to treatment: state of the art. Arch Physiother 2021; 11:8. [PMID: 33775252 PMCID: PMC8006345 DOI: 10.1186/s40945-021-00103-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/22/2021] [Indexed: 01/29/2023] Open
Abstract
Introduction Breast edema can arise from different etiologies; however, it is mostly seen after breast conserving surgery and/or radiotherapy. Combining breast conserving surgery and radiotherapy can cause damage to the lymphatic system and reactions to surrounding tissues, which can lead to breast edema; hereby, the breast size can increase by more than one cup size. Swelling of the breast is not the only criterion associated with breast edema. Other common criteria found in literature are peau d’orange, heaviness of the breast, skin thickening, breast pain, redness of the skin, hyperpigmented skin pores and a positive pitting sign. Despite the benefits of breast conserving surgery, breast edema can be uncomfortable, and can negatively influence quality of life in suffering patients. In contrast to lymphedema of the arm, which is well known in clinical practice and in research, breast edema is often underestimated and far less explored in literature. Currently, many aspects still need to be reviewed. Purpose and importance to practice This masterclass aims at providing the state of the art of breast edema for all health care workers and researchers involved in the treatment and monitoring of breast cancer patients. It includes current and future perspectives on its diagnosis, longitudinal course and treatment. Furthermore, recommendations for clinical practice and future research are discussed. Clinical implications It is recommended to closely monitor those patients in whom breast edema symptoms do not decline within 6 months after termination of radiotherapy and provide them with the appropriate therapy. Since evidence concerning the treatment of breast edema is currently lacking, we recommend the complex decongestive therapy (CDT) to the utmost extent, by analogy with the lymphedema treatment of the extremities. This treatment involves skin care, exercise therapy and compression. Additionally, all patients should be informed about the normal course of breast edema development. Future research priorities A consensus should be reached among clinicians and researchers concerning the definition, assessment methods and best treatment of breast edema. Furthermore, high quality studies are necessary to prove the effectiveness of the CDT for breast edema. Supplementary Information The online version contains supplementary material available at 10.1186/s40945-021-00103-4.
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Affiliation(s)
- Hanne Verbelen
- Department of Rehabilitation Sciences and Physiotherapy (REVAKI-MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Wiebren Tjalma
- Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium.,Multidisciplinary Breast Clinic Antwerp, Antwerp University Hospital (UZA), Wilrijkstraat 10, 2650, Edegem, Belgium.,Oedema Clinic, Antwerp University Hospital and University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Dorien Dombrecht
- Department of Rehabilitation Sciences and Physiotherapy (REVAKI-MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Nick Gebruers
- Department of Rehabilitation Sciences and Physiotherapy (REVAKI-MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Universiteitsplein 1, 2610, Antwerp, Belgium. .,Oedema Clinic, Antwerp University Hospital and University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium.
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18
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de Paula U, D'Angelillo RM, Andrulli AD, Apicella G, Caruso C, Ghini C, Gomellini S, Ponti E, Pompei M, Caccavari A, Petrocchi A, Costarelli L, Giordano M, La Pinta M, Meli EZ, Mauri M, Minelli M, Rossi R, Scavina P, Broglia L, Ponzani T, Loreti A, Fortunato L. Long-Term Outcomes of Once-Daily Accelerated Partial-Breast Irradiation With Tomotherapy: Results of a Phase 2 Trial. Int J Radiat Oncol Biol Phys 2021; 109:678-687. [PMID: 33098960 DOI: 10.1016/j.ijrobp.2020.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 01/18/2023]
Abstract
PURPOSE We report long-term outcomes of phase 2 trial on patients with invasive breast cancer treated with accelerated partial-breast irradiation (APBI) using tomotherapy after breast conservative surgery. METHODS AND MATERIALS From December 2010 to December 2018, we treated 338 women with APBI-tomotherapy: 38.5 Gy in 10 once-daily fractions. Patients selected were age ≥50 years old, with ≤3 cm in size unifocal tumor and at least 2 mm of clear margins. Disease outcomes were analyzed by clinicopathologic characteristics, molecular phenotypes, and American Society for Radiation Oncology (ASTRO) 2017 updated consensus groupings. RESULTS The median age was 65 years (range, 50-86). The invasive ductal (87.5%) and the luminal A-like molecular phenotype (70%) were the most common tumors. Overall 242 patients (71.6%) were considered "suitable" for enrollment in APBI according to the eligibility criteria of the ASTRO-2017 consensus statement. With a median follow-up of 76 months (range, 17-113), 2 patients (0.6%) had an invasive ipsilateral breast tumor recurrence (IBTR), and 2 patients (0.6%) had an axillary ipsilateral failure. The rate of local control in terms of free of IBTR was 99.4% and locoregional control (no recurrence in ipsilateral breast as well as in regional nodes) was 98.8%. Progression-free survival was 98.4% and 92% at 5 and 10 years, respectively. Acute and late skin toxicity, graded according to the Common Terminology Criteria for Adverse Events, were 7.7% (G1) and 0.6% (G2) and 4.4% (G1) and 1.1% (G2), respectively. There were no grade 3/4 toxicities, however. Very few patients (2%) or physicians (2%) assessed cosmetic outcome as fair or poor at the 2-year follow-up. CONCLUSIONS This phase 2 trial on APBI-tomotherapy shows excellent long-term results. Once-daily fractionation schedule was well tolerated with a low rate of adverse events and worse cosmetic outcome. In this series, even among those deemed cautionary or unsuitable for APBI by ASTRO criteria, we demonstrated a low rate of IBTR.
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MESH Headings
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Lobular/diagnostic imaging
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/radiotherapy
- Carcinoma, Lobular/surgery
- Consensus
- Dose Fractionation, Radiation
- Esthetics
- Female
- Humans
- Kaplan-Meier Estimate
- Margins of Excision
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local
- Progression-Free Survival
- Radiotherapy/methods
- Radiotherapy, Intensity-Modulated
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Ugo de Paula
- Radioterapia Oncologica, Ospedale San Giovanni Addolorata, Rome, Italy.
| | - Rolando Maria D'Angelillo
- Radioterapia, Dipartimento di Biomedicina e Prevenzione, Università degli Studi di Roma Tor Vergata, Rome, Italy
| | | | | | - Cristina Caruso
- Radioterapia Oncologica, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Christian Ghini
- Radioterapia Oncologica, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Sara Gomellini
- Radioterapia Oncologica, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Elisabetta Ponti
- Radioterapia Oncologica, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Marco Pompei
- Radioterapia Oncologica, Ospedale San Giovanni Addolorata, Rome, Italy
| | | | | | | | - Marco Giordano
- Anatomia Patologica Ospedale San Giovanni Addolorata, Rome, Italy
| | - Massimo La Pinta
- Chirurgia Senologica Ospedale San Giovanni Addolorata, Rome, Italy
| | | | - Maria Mauri
- Oncologia Medica, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Mauro Minelli
- Oncologia Medica, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Rosalinda Rossi
- Oncologia Medica, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Paola Scavina
- Oncologia Medica, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Laura Broglia
- Diagnostica per Immagini, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Tatiana Ponzani
- Diagnostica per Immagini, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Andrea Loreti
- Chirurgia Plastica e Ricostruttiva, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Lucio Fortunato
- Chirurgia Senologica Ospedale San Giovanni Addolorata, Rome, Italy
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Skin dose in radiation treatment of the left breast: Analysis in the context of prone versus supine treatment technique. Phys Med 2021; 81:114-120. [PMID: 33445123 DOI: 10.1016/j.ejmp.2020.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/22/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine how the skin dose varies in patients receiving radiation treatment for breast cancer in the prone and supine positions. METHODS Fifty patients were scanned in the prone and supine positions. A radiation treatment plan was created for the left breast using a 6-MV beam for a prescribed dose of 42.66 Gy in 16 fractions. The dose was calculated using 1- and 2.5-mm calculation grid sizes and the surface dose was compared in both techniques. RESULTS The median gantry angles relative to the skin surface at the central axis were 8 and 52 degrees for treatment in the prone and supine positions, respectively. The mean dose difference between the prone and supine techniques was statistically significant from 3- to 5-mm depth for both grid sizes. For the 1-mm calculation grid size, the doses at 3-, 4-, and 5-mm depths in the prone and supine techniques were 87.80% and 89.10% (P < 0.003), 91.92% and 94.50% (P < 0.00), and 95.30% and 98.20% (P < 0.00), respectively; for the 2.5-mm grid size, the respective doses were 87.10% and 88.59% (P < 0.00), 91.60% and 94.63% (P < 0.00), and 95.10% and 97.80% (P < 0.00), respectively. CONCLUSIONS This study demonstrates that the prone technique facilitates a relatively lower skin dose than the supine technique. This observation is probably due to the beam angle. The beam is more perpendicular to the skin surface in the prone technique, whereas it is more tangential in the supine technique, which may deliver a higher skin dose. Thus, the dose to the skin should be evaluated in the prone technique, and if desired, the skin dose could be carefully augmented via a bolus or beam spoiler.
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Polgár C, Major T, Takácsi-Nagy Z, Fodor J. Breast-Conserving Surgery Followed by Partial or Whole Breast Irradiation: Twenty-Year Results of a Phase 3 Clinical Study. Int J Radiat Oncol Biol Phys 2020; 109:998-1006. [PMID: 33186620 DOI: 10.1016/j.ijrobp.2020.11.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/22/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE To report the 20-year results of a phase 3 clinical trial comparing the survival and cosmetic results of breast-conserving surgery followed by partial breast irradiation (PBI) or whole breast irradiation (WBI). METHODS AND MATERIALS Between 1998 and 2004, 258 selected patients with low-risk invasive breast carcinoma (pT1 pN0-1mi, grade 1-2, nonlobular breast cancer) resected with negative margins were randomized after breast-conserving surgery to receive PBI (n = 128) or 50 Gy WBI (n = 130). Partial breast irradiation was given either by multicatheter high-dose-rate (HDR) brachytherapy (BT; n = 88) with 7 × 5.2 Gy twice daily or 50 Gy external beam irradiation with electron beams (n = 40). RESULTS Median follow-up time was 17 years. The 20-year actuarial rates of ipsilateral breast tumor recurrences were 9.6% versus 7.9% (P = .59) in the PBI and WBI arms, respectively. There was no significant difference in the 20-year probability of disease-free (79.7% vs 78.3%), cancer-specific (92.6% vs 88.1%), and overall survival (59.5% vs 59.7%). Significantly more patients had excellent or good cosmetic result in the PBI and WBI groups (79.2% vs 59.5%; P = .0007). CONCLUSIONS The 20-year updated results of our phase 3 clinical trial add further scientific evidence that PBI either with multicatheter HDR BT or electron beams for low-risk invasive breast carcinomas yield long-term local tumor control and survival comparable to those achieved with standard WBI. Interstitial HDR BT improved cosmetic results compared with WBI.
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Affiliation(s)
- Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - János Fodor
- Department of Oncology, Semmelweis University, Budapest, Hungary
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Mészáros N, Major T, Stelczer G, Jánváry L, Zaka Z, Pukancsik D, Takácsi-Nagy Z, Md JF, Polgár C. Accelerated partial breast irradiation with 3-dimensional conformal and image-guided intensity-modulated radiotherapy following breast conserving surgery - 7-Year results of a phase II trial. Breast 2020; 54:222-228. [PMID: 33161336 PMCID: PMC7648201 DOI: 10.1016/j.breast.2020.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/05/2020] [Accepted: 10/22/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose To present the 7-year results of accelerated partial breast irradiation (APBI) using three-dimensional conformal (3D-CRT) and image-guided intensity-modulated radiotherapy (IG-IMRT) following breast-conserving surgery (BCS). Patients and methods Between 2006 and 2014, 104 patients were treated with APBI given by means of 3D-CRT using 3–5 non-coplanar, isocentric wedged fields, or IG-IMRT using kV-CBCT. The total dose of APBI was 36.9 Gy (9 × 4.1 Gy) using twice-a-day fractionation. Survival results, side effects and cosmetic results were assessed. Results At a median follow-up of 90 months three (2.9%) local recurrences, one (0.9%) regional recurrence and two (1.9%) distant metastases were observed. The 7-year local (LRFS), recurrence free survival was 98.9%. The 7-year disease-free (DFS), metastases free (MFS) and overall survival (OS) was 94.8%, 97.9% and 94.8%, respectively. Late side effects included G1 skin toxicity in 15 (14.4%), G1, G2, and G3 fibrosis in 26 (25%), 3 (2.9%) and 1 (0.9%) patients respectively. Asymptomatic (G1) fat necrosis occurred in 10 (9.6%) patients. No ≥ G2 or higher late side effects occurred with IMRT. The rate of excellent/good and fair/poor cosmetic results was 93.2% and 6.8%, respectively. Conclusion 7-year results of APBI with 3D-CRT and IG-IMRT are encouraging. Toxicity profile and local tumor control are comparable to other series using multicatheter interstitial brachytherapy. Therefore, these external beam APBI techniques are valid alternatives to whole breast irradiation and brachytherapy based APBI. Phase II APBI trial using 3D-CRT or IG-IMRT. Twice-a-day fractionation, with a total dose of 36.9 Gy (9 × 4.1Gy). No Grade 2 or worst late side effects with IG-IMRT at median follow up of 90 months. These APBI techniques are valid alternatives to WBI or brachytherapy based APBI.
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Affiliation(s)
- Norbert Mészáros
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Gábor Stelczer
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
| | - Levente Jánváry
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Zaka
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Dávid Pukancsik
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - János Fodor Md
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
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22
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Goldberg M, Whelan TJ. Accelerated Partial Breast Irradiation (APBI): Where Are We Now? CURRENT BREAST CANCER REPORTS 2020; 12:275-284. [PMID: 33101597 PMCID: PMC7568840 DOI: 10.1007/s12609-020-00384-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2020] [Indexed: 01/26/2023]
Abstract
Purpose of Review Accelerated partial breast irradiation (APBI) is an alternative approach to breast conserving therapy (BCT) where radiation (RT) is delivered over a shorter period of time compared with whole breast irradiation (WBI), resulting in improved patient convenience and cost savings. APBI can be delivered using brachytherapy, intraoperative RT, or conformal external beam radiation therapy (EBRT) techniques. In this review, the authors appraise the latest modern randomized controlled trials (RCTs) of APBI and discuss the application of the data to clinical practice. Recent Findings The OCOG-RAPID and NSABP B-39/RTOG 0413 trials recently reported long-term outcomes of APBI. The OCOG-RAPID trial delivered 38.5 Gy/10 fractions twice daily (at least 6 h apart using EBRT) or WBI and demonstrated non-inferiority of APBI compared with WBI (8-year cumulative rate of ipsilateral breast tumor recurrence (IBTR) was 3% after APBI or 2.8% after WBI, HR 1.27, 90%CI: 0.84–1.91). While acute toxicity was reduced, late toxicity and breast cosmesis were worse with APBI. The NSABP B-39 trial included higher risk patients and was unable to demonstrate equivalence between APBI (38.5 Gy/10 fractions delivered twice daily using EBRT or brachytherapy techniques) and WBI. However, 10-year IBTR rates were low: 4.6% vs. 3.9%, respectively, HR 1.22, 90%CI: 0.94–1.58. The University of Florence demonstrated low rates of local recurrence at 10 years and overall excellent breast cosmetic outcomes when APBI was delivered using EBRT to a dose of 30 Gy/5 fractions delivered on non-consecutive days. Summary Recent RCTs of APBI have shed light on important factors for the integration of APBI into clinical practice, including patient selection and treatment delivery. APBI should be limited to patients with low-risk ductal carcinoma in situ or early stage (T1) invasive ductal cancer with clear margins of excision, estrogen receptor positivity, and node negative disease. Ongoing research should focus on the optimal dose/fractionation for delivery of EBRT-based APBI.
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Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
| | - Timothy J. Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
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23
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Strnad V, Krug D, Sedlmayer F, Piroth MD, Budach W, Baumann R, Feyer P, Duma MN, Haase W, Harms W, Hehr T, Fietkau R, Dunst J, Sauer R. DEGRO practical guideline for partial-breast irradiation. Strahlenther Onkol 2020; 196:749-763. [PMID: 32350554 PMCID: PMC7449998 DOI: 10.1007/s00066-020-01613-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/19/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE This consensus statement from the Breast Cancer Working Group of the German Society for Radiation Oncology (DEGRO) aims to define practical guidelines for accelerated partial-breast irradiation (APBI). METHODS Recent recommendations for relevant aspects of APBI were summarized and a panel of experts reviewed all the relevant literature. Panel members of the DEGRO experts participated in a series of conferences, supplemented their clinical experience, performed a literature review, and formulated recommendations for implementing APBI in clinical routine, focusing on patient selection, target definition, and treatment technique. RESULTS Appropriate patient selection, target definition for different APBI techniques, and basic rules for appropriate APBI techniques for clinical routine outside of clinical trials are described. Detailed recommendations for APBI in daily practice, including dose constraints, are given. CONCLUSION Guidelines are mandatory to assure optimal results of APBI using different techniques.
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Affiliation(s)
- V Strnad
- University Hospital Erlangen, Erlangen, Germany.
| | - D Krug
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - F Sedlmayer
- Paracelsus Medical University Hospital Salzburg, Salzburg, Austria
| | - M D Piroth
- Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - W Budach
- Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany
| | - R Baumann
- St. Marien-Krankenhaus Siegen, Siegen, Germany
| | - P Feyer
- Vivantes Hospital Neukoelln, Berlin, Germany
| | - M N Duma
- University Hospital, Jena, Germany
| | - W Haase
- St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | - W Harms
- St. Claraspital Basel, Basel, Switzerland
| | - T Hehr
- Marienhospital Stuttgart, Stuttgart, Germany
| | - R Fietkau
- University Hospital Erlangen, Erlangen, Germany
| | - J Dunst
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - R Sauer
- University Hospital Erlangen, Erlangen, Germany
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24
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Belkacemi Y, Debbi K, Loganadane G, Ghith S, Hadhri A, Hassani W, Cherif MA, Coraggio G, To NH, Colson-Durand L, Grellier N. [Adjuvant and neoadjuvant radiotherapy in breast cancer: A literaure review and update on the state of the evidence in 2020]. Cancer Radiother 2020; 24:482-492. [PMID: 32839105 DOI: 10.1016/j.canrad.2020.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 12/19/2022]
Abstract
Radiation therapy has benefited from many developments over the past 20 years. These developments are mainly linked to the technology, imaging and informatics evolutions which allow better targets definitions, ensure better organs-at-risk sparing and excellent reproducibility of treatments, with a perfect control of patient positioning. In breast cancer radiotherapy, the evolution was marked by the possibility of reducing the duration of treatments from 6-7 to 3-4 weeks by using hypofractionated regimens, or by further reducing the irradiation to one week when treatment is solely focalised to the tumour bed. This concept of accelerated partial breast irradiation has challenged the paradigm of the obligation to irradiate the whole breast after conservative surgery in all patients. In addition, the technical mastery of accelerated partial breast irradiation and the development of stereotactic radiotherapy techniques are currently contributing to the development of research projects in neoadjuvant settings. Thus, numerous ongoing studies are evaluating the impact of high-dose preoperative tumour irradiation, alone or in combination with systemic treatments, on biological tumor changes, on anti-tumour immunity, and on the pathologic complete response, which is considered as predictive of better long-term survival in some molecular breast cancer subtypes. In this review, we discuss all these developments which allow breast radiation therapy to enter the era of personalisation of treatments in oncology.
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Affiliation(s)
- Y Belkacemi
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Centre sein Henri-Mondor, hôpitaux universitaires Henri-Mondor, 94010 Créteil, France; Inserm U955 equipe 21, IMRB, 94010 Créteil, France.
| | - K Debbi
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - G Loganadane
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Inserm U955 equipe 21, IMRB, 94010 Créteil, France
| | - S Ghith
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Centre sein Henri-Mondor, hôpitaux universitaires Henri-Mondor, 94010 Créteil, France
| | - A Hadhri
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - W Hassani
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - M A Cherif
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - G Coraggio
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - N H To
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Inserm U955 equipe 21, IMRB, 94010 Créteil, France
| | - L Colson-Durand
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - N Grellier
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Centre sein Henri-Mondor, hôpitaux universitaires Henri-Mondor, 94010 Créteil, France
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25
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Mészáros N, Smanykó V, Major T, Stelczer G, Jánváry L, Kovács E, Mária B, Zaka Z, Pukancsik D, Takácsi-Nagy Z, Polgár C. Implementation of Stereotactic Accelerated Partial Breast Irradiation Using Cyber-Knife - Technical Considerations and Early Experiences of a Phase II Clinical Study. Pathol Oncol Res 2020; 26:2307-2313. [PMID: 32472440 PMCID: PMC7471183 DOI: 10.1007/s12253-020-00821-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 05/12/2020] [Indexed: 12/25/2022]
Abstract
To report the implementation, dosimetric results of and early experiences with stereotactic accelerated partial breast irradiation (SAPBI) following breast conserving surgery (BCS) for postmenopausal low-risk St I-II invasive breast cancer (IBC) patients. Between November 2018 and August 2019, 27 patients were registered in our phase II prospective study. SAPBI was performed with Cyber-Knife (CK) M6 machine, in 4 daily fractions of 6.25 Gy to a total dose of 25 Gy. Respiratory movements were followed with implanted gold markers and Synchrony system. Corrections for patient displacement and respiratory movement during treatment were performed with the robotic arm. Early side effects, cosmetic results, and dosimetric parameters were assessed. The average volume of the surgical cavity, clinical target volume (CTV), and planning target volume (PTV_EVAL) were 8.1 cm3 (range: 1.75–27.3 cm3), 55.3 cm3 (range: 26.2–103.5 cm3), and 75.7 cm3 (range: 40–135.4 cm3), respectively. The mean value of the PTV_eval/whole breast volume ratio was 0.09 (range: 0.04–0.19). No grade 2 or worst acute side-effect was detected. Grade 1 (G1) erythema occurred in 6 (22.2%) patients, while G1 oedema was reported by 3 (11.1%) cases. G1 pain was observed in 1 (3.4%) patient. Cosmetic result were excellent in 17 (62.9%) and good in 10 (37.1%) patients. SAPBI with CK is a suitable and practicable technique for the delivery of APBI after BCS for low-risk, St. I-II. IBC. Our early findings are encouraging, CK-SAPBI performed with four daily fractions is convenient and perfectly tolerated by the patients.
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Affiliation(s)
- Norbert Mészáros
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary. .,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary.
| | - Viktor Smanykó
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary.,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Gábor Stelczer
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Levente Jánváry
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Eszter Kovács
- Department of Radiology, National Institute of Oncology, Budapest, Hungary
| | - Bahéri Mária
- Department of Radiology, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Zaka
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Dávid Pukancsik
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary.,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary.,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
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26
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White J, Thompson A, Whelan T. Accelerated Partial Breast Irradiation and Intraoperative Partial Breast Irradiation: Reducing the Burden of Effective Breast Conservation. J Clin Oncol 2020; 38:2254-2262. [PMID: 32442062 DOI: 10.1200/jco.20.00070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Julia White
- Department of Radiation Oncology, The James, Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Alastair Thompson
- Section of Breast Surgery, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Timothy Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, Ontario, Canada
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27
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Kennedy WR, Roach MC, Thomas MA, Ochoa L, Altman MB, Hernandez-Aya LF, Cyr AE, Margenthaler JA, Zoberi I. Long-Term Outcomes with 3-Dimensional Conformal External Beam Accelerated Partial Breast Irradiation. Pract Radiat Oncol 2020; 10:e128-e135. [DOI: 10.1016/j.prro.2019.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/29/2019] [Accepted: 09/06/2019] [Indexed: 01/20/2023]
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28
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Bosma SCJ, Leij F, Vreeswijk S, Maaker MD, Wesseling J, Vijver MVD, Scholten A, Rivera S, Bourgier C, Auzac G, Foukakis T, Lekberg T, Bongard D, Loo C, Rutgers E, Bartelink H, Elkhuizen PHM. Five-Year Results of the Preoperative Accelerated Partial Breast Irradiation (PAPBI) Trial. Int J Radiat Oncol Biol Phys 2020; 106:958-967. [PMID: 31987957 DOI: 10.1016/j.ijrobp.2019.12.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE In this multicenter phase 2 feasibility study, we investigated the impact of preoperative accelerated partial breast irradiation (PAPBI) on local control, breast fibrosis, and cosmetic outcome. METHODS AND MATERIALS Women aged >60 years with an invasive, unifocal (mammography and magnetic resonance imaging), nonlobular adenocarcinoma of the breast were treated with PAPBI. Six weeks after radiation therapy, a wide local excision was performed. Radiation therapy consisted of 10 × 4 Gy (2010-2013) or 5 × 6 Gy (after 2013) to the tumor (gross target volume) with a 25 mm margin (20 mm from gross target volume to clinical target volume, 5 mm planning target volume). RESULTS One hundred thirty-three patients treated between 2010 and 2016 were analyzed with a median follow-up of 5.0 years (0.9-8.8 years). Seventy-eight (59%) patients were treated with 10 × 4 Gy in 2 weeks and 55 (41%) patients with 5 × 6 Gy in 1 week. Eighteen postoperative complications (14%) occurred in 15 patients (11%). The proportion of patients with no to mild fibrosis in the treated part of the breast at 2 years and later time points was around 90%. Cosmesis improved over time in several patients: excellent to good cosmetic score as rated by the physician was 68% at 6 months and 92% at 5 years. Seventy-seven percent (6 months) to 82% (5 years) of patients were "satisfied" or "very satisfied" with their cosmetic outcome. Three recurrences were detected in the biopsy track and 1 recurrence in the ipsilateral breast. CONCLUSIONS PAPBI is a feasible method with a low postoperative complication rate, limited fibrosis, and good to excellent cosmetic outcome. The local recurrence rate was 3% at 5 years; however, no local recurrences were observed since removal of the needle biopsy track.
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Affiliation(s)
- Sophie C J Bosma
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Femke Leij
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sandra Vreeswijk
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel de Maaker
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Astrid Scholten
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Celine Bourgier
- Department of Radiation Oncology, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | - Guillaume Auzac
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Theodoros Foukakis
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Lekberg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Desiree Bongard
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Claudette Loo
- Department of Radiology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Emiel Rutgers
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Harry Bartelink
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands.
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29
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Whelan TJ, Julian JA, Berrang TS, Kim DH, Germain I, Nichol AM, Akra M, Lavertu S, Germain F, Fyles A, Trotter T, Perera FE, Balkwill S, Chafe S, McGowan T, Muanza T, Beckham WA, Chua BH, Gu CS, Levine MN, Olivotto IA. External beam accelerated partial breast irradiation versus whole breast irradiation after breast conserving surgery in women with ductal carcinoma in situ and node-negative breast cancer (RAPID): a randomised controlled trial. Lancet 2019; 394:2165-2172. [PMID: 31813635 DOI: 10.1016/s0140-6736(19)32515-2] [Citation(s) in RCA: 300] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whole breast irradiation delivered once per day over 3-5 weeks after breast conserving surgery reduces local recurrence with good cosmetic results. Accelerated partial breast irradiation (APBI) delivered over 1 week to the tumour bed was developed to provide a more convenient treatment. In this trial, we investigated if external beam APBI was non-inferior to whole breast irradiation. METHODS We did this multicentre, randomised, non-inferiority trial in 33 cancer centres in Canada, Australia and New Zealand. Women aged 40 years or older with ductal carcinoma in situ or node-negative breast cancer treated by breast conserving surgery were randomly assigned (1:1) to receive either external beam APBI (38·5 Gy in ten fractions delivered twice per day over 5-8 days) or whole breast irradiation (42·5 Gy in 16 fractions once per day over 21 days, or 50 Gy in 25 fractions once per day over 35 days). Patients and clinicans were not masked to treatment assignment. The primary outcome was ipsilateral breast tumour recurrence (IBTR), analysed by intention to treat. The trial was designed on the basis of an expected 5 year IBTR rate of 1·5% in the whole breast irradiation group with 85% power to exclude a 1·5% increase in the APBI group; non-inferiority was shown if the upper limit of the two-sided 90% CI for the IBTR hazard ratio (HR) was less than 2·02. This trial is registered with ClinicalTrials.gov, NCT00282035. FINDINGS Between Feb 7, 2006, and July 15, 2011, we enrolled 2135 women. 1070 were randomly assigned to receive APBI and 1065 were assigned to receive whole breast irradiation. Six patients in the APBI group withdrew before treatment, four more did not receive radiotherapy, and 16 patients received whole breast irradiation. In the whole breast irradiation group, 16 patients withdrew, and two more did not receive radiotherapy. In the APBI group, a further 14 patients were lost to follow-up and nine patients withdrew during the follow-up period. In the whole breast irradiation group, 20 patients were lost to follow-up and 35 withdrew during follow-up. Median follow-up was 8·6 years (IQR 7·3-9·9). The 8-year cumulative rates of IBTR were 3·0% (95% CI 1·9-4·0) in the APBI group and 2·8% (1·8-3·9) in the whole breast irradiation group. The HR for APBI versus whole breast radiation was 1·27 (90% CI 0·84-1·91). Acute radiation toxicity (grade ≥2, within 3 months of radiotherapy start) occurred less frequently in patients treated with APBI (300 [28%] of 1070 patients) than whole breast irradiation (484 [45%] of 1065 patients, p<0·0001). Late radiation toxicity (grade ≥2, later than 3 months) was more common in patients treated with APBI (346 [32%] of 1070 patients) than whole breast irradiation (142 [13%] of 1065 patients; p<0·0001). Adverse cosmesis (defined as fair or poor) was more common in patients treated with APBI than in those treated by whole breast irradiation at 3 years (absolute difference, 11·3%, 95% CI 7·5-15·0), 5 years (16·5%, 12·5-20·4), and 7 years (17·7%, 12·9-22·3). INTERPRETATION External beam APBI was non-inferior to whole breast irradiation in preventing IBTR. Although less acute toxicity was observed, the regimen used was associated with an increase in moderate late toxicity and adverse cosmesis, which might be related to the twice per day treatment. Other approaches, such as treatment once per day, might not adversely affect cosmesis and should be studied. FUNDING Canadian Institutes for Health Research and Canadian Breast Cancer Research Alliance.
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Affiliation(s)
- Timothy J Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada.
| | - Jim A Julian
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Tanya S Berrang
- Radiation Therapy Program, BC Cancer - Victoria, University of British Columbia, Vancouver, BC, Canada
| | - Do-Hoon Kim
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Isabelle Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada
| | - Alan M Nichol
- Division of Radiation Oncology, University of British Columbia and BC Cancer - Vancouver, BC, Canada
| | - Mohamed Akra
- Department of Radiation Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Sophie Lavertu
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Francois Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada; Division of Radiation Oncology, University of British Columbia and BC Cancer - Kelowna, BC, Canada
| | - Anthony Fyles
- Department of Radiation Oncology, University of Toronto and Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Francisco E Perera
- Department of Oncology, Western University and London Regional Cancer Program, London, ON, Canada
| | | | - Susan Chafe
- Department of Oncology, Division of Radiation Oncology, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Thomas McGowan
- Trillium Health Partners Credit Valley Hospital, Mississauga, ON, Canada
| | - Thierry Muanza
- Department of Oncology, McGill University and Jewish General Hospital Segal Cancer Centre, Montreal, QC, Canada
| | - Wayne A Beckham
- Department of Physics and Astronomy, University of Victoria and BC Cancer - Victoria, BC, Canada
| | - Boon H Chua
- University of New South Wales and Prince of Wales Hospital, Sydney, NSW, Australia
| | - Chu Shu Gu
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
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Guidolin K, Yaremko B, Lynn K, Gaede S, Kornecki A, Muscedere G, BenNachum I, Shmuilovich O, Mouawad M, Yu E, Sexton T, Gelman N, Moiseenko V, Brackstone M, Lock M. Stereotactic image-guided neoadjuvant ablative single-dose radiation, then lumpectomy, for early breast cancer: the SIGNAL prospective single-arm trial of single-dose radiation therapy. ACTA ACUST UNITED AC 2019; 26:e334-e340. [PMID: 31285677 DOI: 10.3747/co.26.4479] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Purpose Adjuvant whole-breast irradiation after breast-conserving surgery, typically delivered over several weeks, is the traditional standard of care for low-risk breast cancer. More recently, hypofractionated, partial-breast irradiation has increasingly become established. Neoadjuvant single-fraction radiotherapy (rt) is an uncommon approach wherein the unresected lesion is irradiated preoperatively in a single fraction. We developed the signal (Stereotactic Image-Guided Neoadjuvant Ablative Radiation Then Lumpectomy) trial, a prospective single-arm trial to test our hypothesis that, for low-risk carcinoma of the breast, the preoperative single-fraction approach would be feasible and safe. Methods Patients presenting with early-stage (T < 3 cm), estrogen-positive, clinically node-negative invasive carcinoma of the breast with tumours at least 2 cm away from skin and chest wall were enrolled. All patients received prone breast magnetic resonance imaging (mri) and prone computed tomography simulation. Treatable patients received a single 21 Gy fraction of external-beam rt (as volumetric-modulated arc therapy) to the primary lesion in the breast, followed by definitive surgery 1 week later. The primary endpoints at 3 weeks, 6 months, and 1 year were toxicity and cosmesis (that is, safety) and feasibility (defined as the proportion of mri-appropriate patients receiving rt). Results Of 52 patients accrued, 27 were successfully treated. The initial dosimetric constraints resulted in a feasibility failure, because only 57% of eligible patients were successfully treated. Revised dosimetric constraints were developed, after which 100% of patients meeting mri criteria were treated according to protocol. At 3 weeks, 6 months, and 1 year after the operation, toxicity, patient- and physician-rated cosmesis, and quality of life were not significantly different from baseline. Conclusions The signal trial presents a feasible method of implementing single-dose preoperative rt in early-stage breast cancer. This pilot study did not identify any significant toxicity and demonstrated excellent cosmetic and quality-of-life outcomes. Future randomized multi-arm studies are required to corroborate these findings.
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Affiliation(s)
- K Guidolin
- Department of Surgery, University of Toronto, Toronto, ON
| | - B Yaremko
- Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON.,Schulich School of Medicine and Dentistry, Western University, London, ON
| | - K Lynn
- London Tumour Biobank, St. Joseph's Health Care, London, ON
| | - S Gaede
- Medical Physics, London Regional Cancer Program, London, ON
| | - A Kornecki
- Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON.,Department of Medical Imaging, St. Joseph's Health Care, London, ON
| | - G Muscedere
- Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON.,Department of Medical Imaging, St. Joseph's Health Care, London, ON
| | - I BenNachum
- Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON.,Department of Medical Imaging, St. Joseph's Health Care, London, ON
| | - O Shmuilovich
- Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON.,Department of Medical Imaging, St. Joseph's Health Care, London, ON
| | - M Mouawad
- Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON
| | - E Yu
- Department of Surgery, University of Toronto, Toronto, ON.,Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON
| | - T Sexton
- Department of Surgery, University of Toronto, Toronto, ON.,Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON.,Schulich School of Medicine and Dentistry, Western University, London, ON.,London Tumour Biobank, St. Joseph's Health Care, London, ON.,Medical Physics, London Regional Cancer Program, London, ON.,Department of Medical Imaging, St. Joseph's Health Care, London, ON.,Department of Radiation Medicine and Applied Sciences, School of Medicine, University of California-San Diego, San Diego, U.S.A.,Division of Surgical Oncology, Department of Surgery, London Health Sciences Centre, London, ON
| | - N Gelman
- Department of Medical Imaging, St. Joseph's Health Care, London, ON
| | - V Moiseenko
- Department of Radiation Medicine and Applied Sciences, School of Medicine, University of California-San Diego, San Diego, U.S.A
| | - M Brackstone
- Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON.,Division of Surgical Oncology, Department of Surgery, London Health Sciences Centre, London, ON
| | - M Lock
- Department of Surgery, University of Toronto, Toronto, ON.,Division of Radiation Oncology, Department of Oncology, London Regional Cancer Program, London, ON
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31
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Young-Afat DA, Gregorowitsch ML, van den Bongard DH, Burgmans I, van der Pol CC, Witkamp AJ, Bijlsma RM, Koelemij R, Schoenmaeckers EJ, Jonasse Y, van Gils CH, Verkooijen HM. Breast Edema Following Breast-Conserving Surgery and Radiotherapy: Patient-Reported Prevalence, Determinants, and Effect on Health-Related Quality of Life. JNCI Cancer Spectr 2019; 3:pkz011. [PMID: 31360894 PMCID: PMC6649691 DOI: 10.1093/jncics/pkz011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/03/2019] [Accepted: 03/18/2019] [Indexed: 01/05/2023] Open
Abstract
Background The association between lymphedema of the arm and impaired health-related QoL (HR-QoL) has led to changes in clinical practice. However, data on lymphedema of the breast (ie, breast edema) are lacking. We prospectively evaluated patient-reported prevalence and determinants of breast edema and its effect on patient-reported HR-QoL and breast pain. Methods We prospectively included 836 patients undergoing breast-conserving surgery followed by radiotherapy between October 2013 and October 2016 (UMBRELLA cohort). Patient-reported breast edema, HR-QoL, and breast pain were assessed by means of European Organisation for Research and Treatment of Cancer-C30/BR23 before starting radiotherapy and at 3, 6, 12, and 18 months thereafter. We assessed which patient, tumor, and treatment characteristics were associated with breast edema. With mixed-effects models, we assessed the impact of breast edema on patient-reported HR-QoL domains and breast pain over time, adjusting for confounders. Results Within a median follow-up of 28 months (interquartile range [IQR] = 15), 207 (24.8%) patients reported breast edema at some point in time. Prevalence of breast edema was highest at 6 months (12.4%, 95% confidence interval [CI] = 10.0 to 14.7). Larger tumor size, oncoplastic surgery, axillary lymph node dissection, locoregional radiotherapy, radiotherapy boost on the tumor bed, and adjuvant chemotherapy were associated with breast edema. Breast edema was independently associated with more breast pain and with poorer QoL, physical functioning, and body image. Conclusions Breast edema occurs frequently within the first year after breast-conserving surgery and radiotherapy and is independently associated with impaired HR-QoL and more breast pain. This information is important for use in clinical practice and should be discussed with patients during shared decision making.
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Affiliation(s)
- Danny A Young-Afat
- Imaging Division, University Medical Center, Utrecht, the Netherlands.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands
| | | | | | - Ine Burgmans
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands; Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | | | - Arjen J Witkamp
- Department of Surgery, University Medical Center, Utrecht, the Netherlands
| | - Rhodé M Bijlsma
- Department of Medical Oncology, University Medical Center, Utrecht, the Netherlands
| | - Ron Koelemij
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Carla H van Gils
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands.,Utrecht University, Utrecht, the Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Center, Utrecht, the Netherlands.,Utrecht University, Utrecht, the Netherlands
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32
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Bathily T, Borget I, Rivin Del Campo E, Rivera S, Bourgier C. Partial versus whole breast irradiation: Side effects, patient satisfaction and costs. Cancer Radiother 2019; 23:83-91. [PMID: 30929861 DOI: 10.1016/j.canrad.2018.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/16/2018] [Accepted: 06/08/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Since accelerated partial breast irradiation has demonstrated non-inferiority to whole breast irradiation regarding recurrence rate in patients with early stage breast cancer, our objective was to compare its impact on short-term adverse events, patient satisfaction and costs. MATERIALS AND METHODS Patients with early stage breast cancer treated by breast-conserving surgery between 2007 and 2012 were included: 48 women who received three-dimensional conformal accelerated partial breast irradiation in a multicentre phase-II trial were paired with 48 patients prospectively treated with whole breast irradiation. Adverse events, and patients' opinions concerning cosmesis, satisfaction and pain, were gathered 1 month after treatment. Direct and indirect costs were collected from the French National Health Insurance System perspective until the end of radiotherapy. RESULTS When comparing its impact, skin reactions occurred in 37% of patients receiving three-dimensional conformal accelerated partial breast radiotherapy and 60% of patients receiving whole breast irradiation (P=0.07); 98% were very satisfied in the group three-dimensional conformal accelerated partial breast radiotherapy versus 46% in the group treated with whole breast irradiation (P<0.001); direct costs were significantly lower in the group treated with partial breast irradiation (mean cost: 2510€ versus 5479€/patient), due to less radiation sessions. CONCLUSION In patients with early-stage breast cancer, partial irradiation offered a good alternative to whole breast irradiation, as it was less expensive and satisfactory. These, and the clinical safety and tolerance results, need to be confirmed by long-term accelerated partial breast irradiation results in on-going phase III trials.
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Affiliation(s)
- T Bathily
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - I Borget
- Service de biostatistique et d'épidémiologie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Inserm U1018, CESP, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Université Paris-Sud, université Paris-Saclay, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - E Rivin Del Campo
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France.
| | - S Rivera
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - C Bourgier
- Department of Radiation Oncology, Institut du cancer de Montpellier, 208, avenue des Apothicaires, 34298 Montpellier, France
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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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34
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Hepel JT, Yashar C, Leonard KL, Einck JP, Sha S, DiPetrillo T, Wiggins D, Graves TA, Edmonson D, Wazer DE. Five fraction accelerated partial breast irradiation using noninvasive image-guided breast brachytherapy: Feasibility and acute toxicity. Brachytherapy 2018; 17:825-830. [DOI: 10.1016/j.brachy.2018.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/08/2018] [Accepted: 05/23/2018] [Indexed: 11/25/2022]
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35
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Katz LM, Perez CA, Gerber NK, Purswani J, McCarthy A, Das IJ. Skin recurrence in the radiation treatment of breast cancer. Adv Radiat Oncol 2018; 3:458-462. [PMID: 30202813 PMCID: PMC6128028 DOI: 10.1016/j.adro.2018.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/23/2018] [Accepted: 04/29/2018] [Indexed: 11/02/2022] Open
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Adjuvant Radiation Therapy for T3N0 Breast Cancer Patients Older Than 75 Years After Mastectomy: A SEER Analysis. Clin Breast Cancer 2018; 18:e967-e973. [PMID: 29914691 DOI: 10.1016/j.clbc.2018.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 04/28/2018] [Accepted: 05/08/2018] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Breast cancer patients with tumors > 5 cm but without nodal disease who undergo mastectomy present a clinical challenge regarding the appropriate adjuvant treatment. Traditionally, postmastectomy radiation therapy (PMRT) was the standard of care. However, recent studies have suggested local failure rates without PMRT might be low enough to omit RT. This might be especially true in the elderly. PATIENTS AND METHODS Women aged ≥ 75 years with a diagnosis of T3N0 breast cancer who had undergone mastectomy were identified from the Surveillance, Epidemiology, and End Results (SEER) 18 database. The study period was limited to 2006 to 2009 for more modern sampling. Multivariable proportional hazards modeling was used to examine the association of treatment and mortality, adjusting for demographic and clinicopathologic factors. RESULTS A total of 635 patients were identified. The median follow-up period was 43 months. PMRT was given to 31.2% of the patients aged 75 to 79 years, 21.5% of those aged 80 to 84 years, and 11.7% of the patients aged ≥ 85 years (P < .001). The receipt of PMRT showed a trend toward improved overall survival on bivariable analysis (hazard ratio [HR], 0.58; P < .001) and multivariable analysis (HR, 0.78; P = .14). The 5-year overall survival was 64.2% for those who had received PMRT and 44.8% for those who had not. A nonsignificant trend was seen toward improved breast cancer-specific survival at 5 years on bivariable analysis (HR, 0.63; P = .09) but not on multivariable analysis. The interaction of age and PMRT receipt could have confounded the results. Patient age and tumor grade were significant indicators of the survival prognosis in these patients. CONCLUSION The results of the present analysis of the SEER database suggest that PMRT might still be beneficial in women aged > 75 years with T3N0 disease but also supports continuing efforts to confirm whether it could be safe to omit. It is likely that efforts to subdivide this population using other factors (eg, comorbidity) will be important. The search for refined inclusion and exclusion criteria for adjuvant RT remains an important field of research both clinically and economically.
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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: 0.4] [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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38
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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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39
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In Regard to Rahimi et al. Int J Radiat Oncol Biol Phys 2017; 99:498-499. [DOI: 10.1016/j.ijrobp.2017.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/30/2017] [Indexed: 11/19/2022]
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40
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New Techniques for Irradiating Early Stage Breast Cancer: Stereotactic Partial Breast Irradiation. Semin Radiat Oncol 2017; 27:279-288. [PMID: 28577835 DOI: 10.1016/j.semradonc.2017.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Several improvements in breast cancer radiation delivery have been realized using new techniques over the past several decades. As an example, for early stage disease, there has been active investigation of partial breast irradiation (PBI) vs whole breast irradiation. Although still investigational, PBI reduces the treatment volumes, doses to organs at risk, and may improve cosmesis. Over the past 2 decades PBI has been delivered via interstitial brachytherapy, intracavitary brachytherapy, intraoperative radiation therapy, or 3-dimensional external beam radiation therapy. More recently, there has been growing evidence that supports stereotactic body radiation therapy as a safe and effective new treatment for early stage breast cancer. This article describes this new treatment opportunity and reviews the emerging data of stereotactic partial breast irradiation.
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41
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Sayan M, Wilson K, Nelson C, Gagne H, Rubin D, Heimann R. A novel schedule of accelerated partial breast radiation using intensity-modulated radiation therapy in elderly patients: survival and toxicity analysis of a prospective clinical trial. Radiat Oncol J 2017; 35:32-38. [PMID: 28183159 PMCID: PMC5398344 DOI: 10.3857/roj.2016.01963] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/19/2016] [Accepted: 11/11/2016] [Indexed: 12/30/2022] Open
Abstract
Purpose Several accelerated partial breast radiation (APBR) techniques have been investigated in patients with early-stage breast cancer (BC); however, the optimal treatment delivery techniques remain unclear. We evaluated the feasibility and toxicity of APBR delivered using intensity-modulated radiation therapy (IMRT) in elderly patients with stage I BC, using a novel fractionation schedule. Materials and Methods Forty-two patients aged ≥65 years, with stage I BC who underwent breast conserving surgery were enrolled in a phase I/II study evaluating APBR using IMRT. Forty eligible patients received 40 Gy in 4 Gy daily fractions. Patients were assessed for treatment related toxicities, and cosmesis, before APBR, during, and after completion of the treatment. Results The median age was 73 years, median tumor size 0.8 cm and the median follow-up was 54 months. The 5-year locoregional control was 97.5% and overall survival 90%. Erythema and skin pigmentation was the most common acute adverse event, reported by 27 patients (69%). Twenty-six patients (65%) reported mild pain, rated 1-4/10. This improved at last follow-up to only 2 (15%). Overall the patient and physician reported worst late toxicities were lower than the baseline and at last follow-up, patients and physicians rated cosmesis as excellent/good in 93% and 86 %, respectively. Conclusion In this prospective trial, we observed an excellent rate of tumor control with daily APBR. The acceptable toxicity profile and cosmetic results of this study support 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
| | - 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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Polgár C, Ott OJ, Hildebrandt G, Kauer-Dorner D, Knauerhase H, Major T, Lyczek J, Guinot JL, Dunst J, Miguelez CG, Slampa P, Allgäuer M, Lössl K, Polat B, Kovács G, Fischedick AR, Fietkau R, Resch A, Kulik A, Arribas L, Niehoff P, Guedea F, Schlamann A, Pötter R, Gall C, Uter W, Strnad V. Late side-effects and cosmetic results of accelerated partial breast irradiation with interstitial brachytherapy versus whole-breast irradiation after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: 5-year results of a randomised, controlled, phase 3 trial. Lancet Oncol 2017; 18:259-268. [PMID: 28094198 DOI: 10.1016/s1470-2045(17)30011-6] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/19/2016] [Accepted: 10/20/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND We previously confirmed the non-inferiority of accelerated partial breast irradiation (APBI) with interstitial brachytherapy in terms of local control and overall survival compared with whole-breast irradiation for patients with early-stage breast cancer who underwent breast-conserving surgery in a phase 3 randomised trial. Here, we present the 5-year late side-effects and cosmetic results of the trial. METHODS We did this randomised, controlled, phase 3 trial at 16 centres in seven European countries. Women aged 40 years or older with stage 0-IIA breast cancer who underwent breast-conserving surgery with microscopically clear resection margins of at least 2 mm were randomly assigned 1:1, via an online interface, to receive either whole-breast irradiation of 50 Gy with a tumour-bed boost of 10 Gy or APBI with interstitial brachytherapy. Randomisation was stratified by study centre, menopausal status, and tumour type (invasive carcinoma vs ductal carcinoma in situ), with a block size of ten, according to an automated dynamic algorithm. Patients and investigators were not masked to treatment allocation. The primary endpoint of our initial analysis was ipsilateral local recurrence; here, we report the secondary endpoints of late side-effects and cosmesis. We analysed physician-scored late toxicities and patient-scored and physician-scored cosmetic results from the date of breast-conserving surgery to the date of onset of event. Analysis was done according to treatment received (as-treated population). This trial is registered with ClinicalTrials.gov, number NCT00402519. FINDINGS Between April 20, 2004, and July 30, 2009, we randomly assigned 1328 women to receive either whole-breast irradiation (n=673) or APBI with interstitial brachytherapy (n=655); 1184 patients comprised the as-treated population (551 in the whole-breast irradiation group and 633 in the APBI group). At a median follow-up of 6·6 years (IQR 5·8-7·6), no patients had any grade 4 toxities, and three (<1%) of 484 patients in the APBI group and seven (2%) of 393 in the whole-breast irradiation group had grade 3 late skin toxicity (p=0·16). No patients in the APBI group and two (<1%) in the whole-breast irradiation group developed grade 3 late subcutaneous tissue toxicity (p=0·10). The cumulative incidence of any late side-effect of grade 2 or worse at 5 years was 27·0% (95% CI 23·0-30·9) in the whole-breast irradiation group versus 23·3% (19·9-26·8) in the APBI group (p=0·12). The cumulative incidence of grade 2-3 late skin toxicity at 5 years was 10·7% (95% CI 8·0-13·4) in the whole-breast irradiation group versus 6·9% (4·8-9·0) in the APBI group (difference -3·8%, 95% CI -7·2 to 0·4; p=0·020). The cumulative risk of grade 2-3 late subcutaneous tissue side-effects at 5 years was 9·7% (95% CI 7·1-12·3) in the whole-breast irradiation group versus 12·0% (9·4-14·7) in the APBI group (difference 2·4%; 95% CI -1·4 to 6·1; p=0·28). The cumulative incidence of grade 2-3 breast pain was 11·9% (95% CI 9·0-14·7) after whole-breast irradiation versus 8·4% (6·1-10·6) after APBI (difference -3·5%; 95% CI -7·1 to 0·1; p=0·074). At 5 years' follow-up, according to the patients' view, 413 (91%) of 454 patients had excellent to good cosmetic results in the whole-breast irradiation group versus 498 (92%) of 541 patients in the APBI group (p=0·62); when judged by the physicians, 408 (90%) of 454 patients and 503 (93%) of 542 patients, respectively, had excellent to good cosmetic results (p=0·12). No treatment-related deaths occurred, but six (15%) of 41 patients (three in each group) died from breast cancer, and 35 (85%) deaths (21 in the whole-breast irradiation group and 14 in the APBI group) were unrelated. INTERPRETATION 5-year toxicity profiles and cosmetic results were similar in patients treated with breast-conserving surgery followed by either APBI with interstitial brachytherapy or conventional whole-breast irradiation, with significantly fewer grade 2-3 late skin side-effects after APBI with interstitial brachytherapy. These findings provide further clinical evidence for the routine use of interstitial multicatheter brachytherapy-based APBI in the treatment of patients with low-risk breast cancer who opt for breast conservation. FUNDING German Cancer Aid.
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Affiliation(s)
- Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
| | - Oliver J Ott
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany; Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | | | - Hellen Knauerhase
- Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Jaroslaw Lyczek
- Brachytherapy Department, Centrum Onkologii-Instytut im Marii Skłodowskiej, Warsaw, Poland; Podkarpacki Hospital Cancer Center Brzozów, Brzozów, Poland
| | - José Luis Guinot
- Department of Radiation Oncology, Valencian Institute of Oncology, Valencia, Spain
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Kiel, Kiel, Germany
| | | | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Michael Allgäuer
- Department of Radiation Oncology, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Kristina Lössl
- Department of Radiation Oncology, University Hospital Bern, Inselspital, Switzerland
| | - Bülent Polat
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
| | - György Kovács
- Interdisciplinary Brachytherapy Unit, University of Lübeck/Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | | | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany; Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Alexandra Resch
- Department of Radiation Oncology, University Hospital AKH Wien, Vienna, Austria
| | - Anna Kulik
- Brachytherapy Department, Centrum Onkologii-Instytut im Marii Skłodowskiej, Warsaw, Poland
| | - Leo Arribas
- Department of Radiation Oncology, Valencian Institute of Oncology, Valencia, Spain
| | - Peter Niehoff
- Department of Radiation Oncology, University Hospital Kiel, Kiel, Germany; Department of Radiotherapy, Sana Hospital Offenbach, Offenbach, Germany
| | - Ferran Guedea
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
| | - Annika Schlamann
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany
| | - Richard Pötter
- Department of Radiation Oncology, University Hospital AKH Wien, Vienna, Austria
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Erlangen, Germany
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
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Sanford NN, Taghian AG. Accelerated Partial Breast Irradiation. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rabinovitch R, Moughan J, Vicini F, Pass H, Wong J, Chafe S, Petersen I, Arthur DW, White J. Long-Term Update of NRG Oncology RTOG 0319: A Phase 1 and 2 Trial to Evaluate 3-Dimensional Conformal Radiation Therapy Confined to the Region of the Lumpectomy Cavity for Stage I and II Breast Carcinoma. Int J Radiat Oncol Biol Phys 2016; 96:1054-1059. [PMID: 27869081 PMCID: PMC5226218 DOI: 10.1016/j.ijrobp.2016.08.042] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/02/2016] [Accepted: 09/20/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE NRG Oncology RTOG 0319 was the first cooperative group trial in the United States to evaluate 3-dimensional conformal radiation therapy (3D-CRT) accelerated partial breast irradiation (APBI). This report updates secondary endpoints of toxicity and efficacy. METHODS AND MATERIALS Patients with stage I or II invasive breast cancer (tumor size ≤3 cm, ≤3 positive lymph nodes, negative margins) were eligible for 3D-CRT APBI: 38.5 Gy in 10 twice-daily fractions. Patient characteristics and treatment details have previously been reported. Adverse events were graded with CTCAE v3.0 (National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0). This analysis updates the rates of ipsilateral breast recurrence (IBR), contralateral breast recurrence, ipsilateral node recurrence (INR), metastatic sites (distant metastases [DM]), mastectomy, disease-free survival, mastectomy-free survival, and overall survival. RESULTS Of 58 enrolled patients, 52 were eligible, with a median age of 61 years; 94% had stage I cancer and 83% had estrogen receptor positive disease. The median follow-up period was 8 years (minimum-maximum, 1.7-9.0 years). The 7-year estimate of isolated IBR (no DM) was 5.9%. The 7-year estimates of all IBRs, INR, mastectomy rate, and DM were 7.7%, 5.8%, 7.7%, and 7.7%, respectively. All 4 IBRs were invasive, of which 3 had a component within the planning target volume. The patterns of failure were as follows: 3 IBRs, 1 INR, 2 DM, 1 INR plus DM, and 1 IBR plus INR plus DM. The 7-year estimates of mastectomy-free survival, disease-free survival, and overall survival were 71.2%, 71.2%, and 78.8%, respectively. Thirteen patients died: 3 of breast cancer and 10 of other causes. Grade 3 (G3) treatment-related adverse events were reported by 4 patients (7.7%). No G3 pain or pulmonary or cardiac toxicities were reported. CONCLUSIONS This phase 1 and 2 trial of 3D-CRT APBI continues to show durable tumor control and minimal G3 toxicity, comparable to other APBI techniques. Mature phase 3 results will determine the appropriateness and limitations of this noninvasive APBI technique.
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Affiliation(s)
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Frank Vicini
- Radiation Oncology, St Joseph Mercy Oakland, Pontiac, Michigan
| | - Helen Pass
- Surgery, Stamford Hospital, Stamford, Connecticut
| | - John Wong
- Medical Physics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan Chafe
- Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Ivy Petersen
- Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Douglas W Arthur
- Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Julia White
- Radiation Oncology, The Ohio State University Medical Center, Columbus, Ohio
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Mészáros N, Major T, Stelczer G, Zaka Z, Mózsa E, Pukancsik D, Takácsi-Nagy Z, Fodor J, Polgár C. Implementation of image-guided intensity-modulated accelerated partial breast irradiation : Three-year results of a phase II clinical study. Strahlenther Onkol 2016; 193:70-79. [PMID: 27872946 DOI: 10.1007/s00066-016-1074-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/19/2016] [Indexed: 01/19/2023]
Abstract
PURPOSE To report 3‑year results of accelerated partial breast irradiation (APBI) using image-guided intensity-modulated radiotherapy (IG-IMRT) following breast conserving surgery (BCS) for low-risk early invasive breast cancer. PATIENTS AND METHODS Between July 2011 and March 2014, 60 patients with low-risk early invasive breast cancer underwent BCS and were enrolled in this phase II prospective study. The total dose was 36.9 Gy (9 fractions of 4.1 Gy, two fractions/day). Patient setup errors were detected in LAT, LONG and VERT directions. Local tumour control, survival results, early and late side effects and cosmetic outcome were assessed. RESULTS At a median follow-up of 39 months, all patients were alive and neither locoregional nor distant failure occurred. One contralateral breast cancer and two new primary malignancies outside the breast were observed. No grade (G) 3-4 acute toxicity was detected. G1 and G2 erythema occurred in 21 (35%) and 2 (3.3%) patients, respectively; while G1 oedema was observed in 23 (38.8%) cases. G1 and G2 pain was reported by 6 (10%) and 2 (3.3%) patients, respectively. Among the late radiation side effects, G1 pigmentation or telangiectasia, G1 fibrosis and G1 asymptomatic fat necrosis occurred in 10 (16.7%), 7 (11.7%) and 3 (5%) patients, respectively. No ≥ G2 late toxicity was detected. Cosmetic outcome was excellent in 43 (71.7%) and good in 17 (28.3%) patients. CONCLUSION IG-IMRT is a reproducible and feasible technique for delivery of external beam APBI following BCS for treatment of low-risk, early-stage invasive breast carcinoma. In order to avoid toxicity, image guidance performed before each radiation fraction is necessary to minimize the PTV. Three-year results are promising, early and late radiation side-effects are minimal, and cosmetic results are excellent to good.
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Affiliation(s)
- Norbert Mészáros
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
| | - Gábor Stelczer
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
| | - Zoltán Zaka
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
| | - Emőke Mózsa
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary.,Department of Radiooncology and Radiotherapy, Landesklinikum, Wiener Neustadt, Austria
| | - Dávid Pukancsik
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
| | - János Fodor
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
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Chand-Fouché ME, Lam Cham Kee D, Gautier M, Hannoun-Levi JM. Technique d’irradiation partielle du sein : radiothérapie externe et curiethérapie. Cancer Radiother 2016; 20:587-94. [DOI: 10.1016/j.canrad.2016.07.087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/12/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
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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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Mondal D, Sharma DN. External beam radiation techniques for breast cancer in the new millennium: New challenging perspectives. J Egypt Natl Canc Inst 2016; 28:211-218. [PMID: 27595191 DOI: 10.1016/j.jnci.2016.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/26/2016] [Accepted: 08/01/2016] [Indexed: 11/17/2022] Open
Abstract
Radiation therapy in breast cancer has evolved dramatically over the past century. It has traveled a long path touching different milestones and taking unprecedented turns. At the end, a fine tune of clinical understanding, skill, technological advancement and translation of radiobiological understanding to clinical outcome has taken place. What all these have given is better survival with quality survivorship. It is thus prudent to understand breast irradiation in a new perspective suitable for the current millennium.
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Affiliation(s)
- Dodul Mondal
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Daya Nand Sharma
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi 110029, India
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Five-year results of a prospective clinical trial investigating accelerated partial breast irradiation using 3D conformal radiotherapy after lumpectomy for early stage breast cancer. Breast 2016; 28:178-83. [DOI: 10.1016/j.breast.2016.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/09/2016] [Accepted: 06/01/2016] [Indexed: 01/19/2023] Open
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Lakosi F, Gulyban A, Simoni SBM, Nguyen PV, Cucchiaro S, Seidel L, Janvary L, Nicolas S, Vavassis P, Coucke P. The Influence of Treatment Position (Prone vs. Supine) on Clip Displacement, Seroma, Tumor Bed and Partial Breast Target Volumes: Comparative Study. Pathol Oncol Res 2015; 22:493-500. [PMID: 26676979 DOI: 10.1007/s12253-015-0028-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 12/10/2015] [Indexed: 10/22/2022]
Abstract
To analyse the displacement of surgical clips in prone (Pr) position and assess the consequences on target volumes and integral dose of partial breast irradiation (PBI). 30 post-lumpectomy breast cancer patients underwent CT imaging in supine (Su) and Pr. Clip displacements were measured by the distances from the clips to a common fix bony reference point. On each dataset, the tumour bed (TB = clips ± seroma), clinical target volume (CTV = TB + 1.5 cm) and planning target volumes (PTV = CTV + 1 cm) for PBI were determined and the volume pairs were compared. Furthermore estimation of integral dose ratio (IDR) within the breast from tangential treatment was performed as the ratio of the irradiated breast volume and the volume encompassing all clips. Clips close to the chest wall (CW) in Su showed significantly less displacement in Pr. The mean volumes of seroma, CTV and PTV were significantly higher in Pr than in Su. The PTV volume difference (Pr-Su) was significantly higher in patients with presence of seroma, deep clips and TB location in the superior-internal-quadrant (SIQ) and at the junction of superior quadrants (jSQ). In a multivariate analysis two factors remained significant: seroma and TB localization in SIQ-jSQ. The IDR was significantly larger in Su than in Pr (7.6 vs. 4.1 p < 0.01). Clip displacements varied considerably with respect to their relative position to the CW. In selected patients Pr position potentially leads to a significant increase in target volumes of PBI. Tangential beam arrangement for PBI should be avoided, not only in Su but in Pr as well in case of clip-based target volume definition.
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Affiliation(s)
- Ferenc Lakosi
- Department of Radiation Oncology, University Hospital of Liège, Domain University of Sart Tilman, B.35, B-4000, Liège 1, Belgium.
| | - Akos Gulyban
- Department of Radiation Oncology, University Hospital of Liège, Domain University of Sart Tilman, B.35, B-4000, Liège 1, Belgium
| | - Selma Ben-Mustapha Simoni
- Department of Radiation Oncology, University Hospital of Liège, Domain University of Sart Tilman, B.35, B-4000, Liège 1, Belgium
| | - Paul Viet Nguyen
- Department of Radiation Oncology, University Hospital of Liège, Domain University of Sart Tilman, B.35, B-4000, Liège 1, Belgium
| | - Séverine Cucchiaro
- Department of Radiation Oncology, University Hospital of Liège, Domain University of Sart Tilman, B.35, B-4000, Liège 1, Belgium
| | - Laurence Seidel
- Department of Biostatistics, University Hospital of Liège, Liège, Belgium
| | - Levente Janvary
- Department of Radiation Oncology, Debrecen University, Debrecen, Hungary
| | - Sophie Nicolas
- Department of Radiation Oncology, University Hospital of Liège, Domain University of Sart Tilman, B.35, B-4000, Liège 1, Belgium
| | - Peter Vavassis
- Department of Radiation Oncology, Hôpital Maisonneuve-Rosemont, Montreal, Québec, Canada
| | - Philippe Coucke
- Department of Radiation Oncology, University Hospital of Liège, Domain University of Sart Tilman, B.35, B-4000, Liège 1, Belgium
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