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Ning J, Cheng G, Wu N. A systematic review on the techniques, long-term outcomes, and complications of partial breast irradiation after breast-conserving surgery for early-stage breast cancer. Sci Rep 2024; 14:22283. [PMID: 39333210 PMCID: PMC11436892 DOI: 10.1038/s41598-024-73627-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Accepted: 09/19/2024] [Indexed: 09/29/2024] Open
Abstract
To evaluate the efficacy and safety of four techniques of partial breast irradiation (PBI) including interstitial brachytherapy (ISBT), balloon-based brachytherapy (BBT), Intraoperative radiotherapy (IORT) and three-dimensional conformal radiotherapy (3DCRT) in the treatment for early-stage breast cancer patients after breast-conserving surgery. A systematic search was performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed, Embase, Cochrane Library and Web of Science databases. The inclusion criteria were clinical trials and observational studies that reported on outcome measures of principal PBI techniques. The methodological quality of the included research data was assessed using bias risk assessment tool with the Methodological Index for Non-Randomized Studies (MINORS), and the research information were analyzed using data analysis software. Clinical studies were collected from the earliest available date until September 2023. Fifty-one studies were included, with a total sample size of 7708. The results of network meta-analysis (NMA) showed that ISBT can lower the local recurrence (SUCRA: 73.8%). In terms of reducing distant metastasis, 3DCRT may be the best choice (SUCRA: 52.5%). And IORT has the highest 5-year overall survival (SUCRA: 90%). Furthermore, ISBT also has the advantages of lowest risk with fat necrosis (SUCRA: 72.5%), infection (SUCRA: 78.3%) and breast pain (SUCRA: 86.2%). BBT may be the optimal solution for fibrosis (SUCRA: 76.9%) and hyperpigmentation (SUCRA: 66.7%). 3DCRT has lower incidence of telangiectasia (SUCRA: 56.7%) and better cosmetic result (SUCRA: 85%). Postoperative PBI treatment using ISBT after breast-conserving surgery in patients with early-stage breast cancer may be a more valuable choice based on the treatment efficacy and is associated with fewer late side-effects. Large-scale, prospective, long-term studies are warranted to clarify the role of different PBI techniques in selected patients.
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Affiliation(s)
- Jing Ning
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, 130033, Changchun, Jilin, China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, 130033, Changchun, Jilin, China
| | - Ning Wu
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, 130033, Changchun, Jilin, China.
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Haussmann J, Budach W, Corradini S, Krug D, Jazmati D, Tamaskovics B, Bölke E, Pedotoa A, Kammers K, Matuschek C. Comparison of adverse events in partial- or whole breast radiotherapy: investigation of cosmesis, toxicities and quality of life in a meta-analysis of randomized trials. Radiat Oncol 2023; 18:181. [PMID: 37919752 PMCID: PMC10623828 DOI: 10.1186/s13014-023-02365-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE/OBJECTIVE Adjuvant whole breast radiotherapy and systemic therapy are part of the current evidence-based treatment protocols for early breast cancer, after breast-conserving surgery. Numerous randomized trials have investigated the therapeutic effects of partial breast irradiation (PBI) compared to whole breast irradiation (WBI), limiting the treated breast tissue. These trials were designed to achieve equal control of the disease with possible reduction in adverse events, improvements in cosmesis and quality of life (QoL). In this meta-analysis, we aimed to investigate the differences between PBI and WBI in side effects and QoL. MATERIAL/METHODS We performed a systematic literature review searching for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was performed using the published event rates and the effect-sizes for available acute and late adverse events. Additionally, we evaluated cosmetic outcomes as well as general and breast-specific QoL using the EORTC QLQ-C30 and QLQ-BR23 questionnaires. RESULTS Sixteen studies were identified (n = 19,085 patients). PBI was associated with a lower prevalence in any grade 1 + acute toxicity and grade 2 + skin toxicity (OR = 0.12; 95% CI 0.09-0.18; p < 0.001); (OR = 0.16; 95% CI 0.07-0.41; p < 0.001). There was neither a significant difference in late adverse events between the two treatments, nor in any unfavorable cosmetic outcomes, rated by either medical professionals or patients. PBI-technique using EBRT with twice-daily fractionation schedules resulted in worse cosmesis rated by patients (n = 3215; OR = 2.08; 95% CI 1.22-3.54; p = 0.007) compared to WBI. Maximum once-daily EBRT schedules (n = 2071; OR = 0.60; 95% CI 0.45-0.79; p < 0.001) and IORT (p = 0.042) resulted in better cosmetic results grade by medical professionals. Functional- and symptom-based QoL in the C30-scale was not different between PBI and WBI. Breast-specific QoL was superior after PBI in the subdomains of "systemic therapy side effects" as well as "breast-" and "arm symptoms". CONCLUSION The analysis of multiple randomized trials demonstrate a superiority of PBI in acute toxicity as well breast-specific quality of life, when compared with WBI. Overall, late toxicities and cosmetic results were similar. PBI-technique with a fractionation of twice-daily schedules resulted in worse cosmesis rated by patients.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, Ludwig Maximillian University, Munich, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Bálint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alessia Pedotoa
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Kai Kammers
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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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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4
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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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5
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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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Pugh SL, Rodgers JP, Moughan J, Bonanni R, Boparai J, Chen RC, Dignam JJ, Bruner DW. Do reminder emails and past due notifications improve patient completion and institutional data submission for patient-reported outcome measures? Qual Life Res 2020; 30:81-89. [PMID: 32894431 DOI: 10.1007/s11136-020-02613-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE NRG Oncology, part of the National Cancer Institute's National Clinical Trials Network, took efforts to increase patient-reported outcome measures (PROMs) completion and institutional data submission rates within clinical trials. Lack of completion diminishes power to draw conclusions and can be a waste of resources. It is hypothesized that trials with automatic email reminders and past due notifications will have PROM forms submitted more timely with higher patient completion. METHODS Automatic emails sent to the research associate were added to selected NRG Oncology trials. Comparisons between trials with and without automatic emails were analyzed using Chi-square tests with respect to patient completion and timeliness of form submission rates. Multivariable analyses were conducted using repeated measures generalized estimating equations. If PROMs were not completed, a form providing the reason why was submitted and counted towards form submission. RESULTS For both disease sites, form submission was significantly higher within 1 month of the form's due date for the studies with automatic emails vs. those without (prostate: 79.7% vs. 75.7%, p < 0.001; breast: 59.2% vs. 31.3%, p < 0.001). No significant differences in patient completion were observed between the breast trials. The prostate trial with automatic emails had significantly higher patient completion but this result was not confirmed in the multivariable analysis. CONCLUSIONS Although patient completion rates were higher on trials with automatic emails, there may be confounding factors requiring future study. The automatic emails appeared to have increased the timeliness of form submission, thus supporting their continued use on NRG Oncology trials.
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Affiliation(s)
- Stephanie L Pugh
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA, USA.
| | - Joseph P Rodgers
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA, USA
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA, USA
| | - Roseann Bonanni
- NRG Oncology Statistics and Data Management Center, American College of Radiology, Philadelphia, PA, USA
| | - Jaskaran Boparai
- NRG Oncology Operations Center, American College of Radiology, Philadelphia, PA, USA
| | | | - James J Dignam
- NRG Oncology Statistics and Data Management Center, University of Chicago, Chicago, IL, USA
| | - Deborah W Bruner
- Emory University Hospital/Winship Cancer Institute, Atlanta, GA, USA
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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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8
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Shah C, Vicini F. Accelerated partial breast irradiation-Redefining the treatment target for women with early stage breast cancer. Breast J 2019; 25:408-417. [PMID: 30950133 DOI: 10.1111/tbj.13241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/07/2018] [Accepted: 06/19/2018] [Indexed: 01/19/2023]
Abstract
Following breast conserving surgery, the standard of care has been to deliver adjuvant radiation therapy directed to the whole breast (WBI) over a period of 3-7 weeks. Over the past decade, increasing data have supported the concept that treatment to the whole breast may not be required in selected patients, allowing for the emergence of partial breast irradiation (PBI). Multiple randomized trials with 5-10 years of follow-up have been published documenting the safety and efficacy associated with PBI using multiple techniques. Questions that remain to be answered include (a) what is the optimal PBI technique for each clinical scenario, (b) are there additional patients that can be effectively managed with PBI approaches, and (c) are there different techniques/dose schedules that allow for further reduction in treatment duration and/or toxicities? Partial breast irradiation represents a standard approach for appropriately selected patients. PBI provides comparable clinical outcomes to WBI while allowing for a reduction in the duration treatment and the potential for reduced toxicities. Future studies may also help to better define which patients require no radiation, PBI, hypofractionated WBI or conventional WBI, based upon patient, clinical, pathologic features as well as potentially using tumor genetics.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Frank Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, Michigan
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Shah C, Ward MC, Tendulkar RD, Cherian S, Vicini F, Singer ME. Cost and Cost-Effectiveness of Image Guided Partial Breast Irradiation in Comparison to Hypofractionated Whole Breast Irradiation. Int J Radiat Oncol Biol Phys 2019; 103:397-402. [DOI: 10.1016/j.ijrobp.2018.09.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/08/2018] [Accepted: 09/17/2018] [Indexed: 10/28/2022]
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10
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Wang K, Yee C, Tam S, Drost L, Chan S, Zaki P, Rico V, Ariello K, Dasios M, Lam H, DeAngelis C, Chow E. Prevalence of pain in patients with breast cancer post-treatment: A systematic review. Breast 2018; 42:113-127. [DOI: 10.1016/j.breast.2018.08.105] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/08/2018] [Accepted: 08/27/2018] [Indexed: 12/12/2022] Open
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Bennion NR, Baine M, Granatowicz A, Wahl AO. Accelerated partial breast radiotherapy: a review of the literature and future directions. Gland Surg 2018; 7:596-610. [PMID: 30687631 DOI: 10.21037/gs.2018.11.05] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Breast conservation therapy exemplifies the tailoring of medicine in the care of patients with cancer. Akin to improvements in surgical approaches, accelerated partial breast irradiation (APBI) tailors the treatment volume and duration to the needs of well selected patients. Here, we examine the evidence supporting APBI as well as the lessons in patient selection, dose and delivery techniques. Examination of historical techniques and their associated outcomes will support more correct patient selection and treatment delivery in an era where we await the reports of several large prospective trials.
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Affiliation(s)
- Nathan R Bennion
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael Baine
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Andrew O Wahl
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
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12
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Gelover E, Katherine C, Mart C, Sun W, Kim Y. Patient's specific integration of OAR doses (D2 cc) from EBRT and 3D image-guided brachytherapy for cervical cancer. J Appl Clin Med Phys 2018; 19:83-92. [PMID: 29349933 PMCID: PMC5849844 DOI: 10.1002/acm2.12247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/17/2017] [Accepted: 11/28/2017] [Indexed: 01/03/2023] Open
Abstract
The objective of this study was to assess the recommended DVH parameter (e.g., D2 cc) addition method used for combining EBRT and HDR plans, against a reference dataset generated from an EQD2‐based DVH addition method. A revised DVH parameter addition method using EBRT DVH parameters derived from each patient's plan was proposed and also compared with the reference dataset. Thirty‐one biopsy‐proven cervical cancer patients who received EBRT and HDR brachytherapy were retrospectively analyzed. A parametrial and/or paraaortic EBRT boost were clinically performed on 13 patients. Ten IMRT and 21 3DCRT plans were determined. Two different HDR techniques for each HDR plan were analyzed. Overall D2 cc and D0.1 cc OAR doses in EQD2 were statistically analyzed for three different DVH parameter addition methods: a currently recommended method, a proposed revised method, and a reference DVH addition method. The overall D2 ccEQD2 values for all rectum, bladder, and sigmoid for a conformal, volume optimization HDR plan generated using the current DVH parameter addition method were significantly underestimated on average −5 to −8% when compared to the values obtained from the reference DVH addition technique (P < 0.01). The revised DVH parameter addition method did not present statistical differences with the reference technique (P > 0.099). When PM boosts were considered, there was an even greater average underestimation of −8~−10% for overall OAR doses of conformal HDR plans when using the current DVH parameter addition technique as compared to the revised DVH parameter addition. No statistically significant differences were found between the 3DCRT and IMRT techniques (P > 0.3148). It is recommended that the overall D2 cc EBRT doses are obtained from each patient's EBRT plan.
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Affiliation(s)
- Edgar Gelover
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cabel Katherine
- College of Engineering, Department of Biomedical Engineering, The University of Iowa, Iowa City, IA, USA
| | - Christopher Mart
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Wenqing Sun
- College of Engineering, Department of Biomedical Engineering, The University of Iowa, Iowa City, IA, USA
| | - Yusung Kim
- College of Engineering, Department of Biomedical Engineering, The University of Iowa, Iowa City, IA, USA
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The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation. Brachytherapy 2018; 17:154-170. [DOI: 10.1016/j.brachy.2017.09.004] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 12/29/2022]
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14
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Impact of a Novel Bioabsorbable Implant on Radiation Treatment Planning for Breast Cancer. World J Surg 2017; 41:464-471. [PMID: 27709273 DOI: 10.1007/s00268-016-3711-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Techniques for accurately delineating the tumor bed after breast-conserving surgery (BCS) can be challenging. As a result, the accuracy, and efficiency of radiation treatment (RT) planning can be negatively impacted. Surgically placed clips or the post-surgical seroma are commonly used to determine target volume; however, these methods can lead to a high degree of uncertainty and variability. A novel 3-dimensional bioabsorbable marker was used during BCS and assessed for its impact on RT planning. METHODS One hundred and ten implants were sutured to the margins of the tumor bed excision site in 108 patients undergoing BCS. Routine CT imaging of the breast tissue was performed for RT planning, and the marker was assessed for visibility and utility in target delineation. RT regimens, target volumes and associated treatment costs were analyzed. RESULTS In all patients, the marker was easily visible and in 95.7 % of cases, it proved useful for RT planning. 36.8 % of patients received conventional whole breast irradiation plus boost, 56.6 % received hypo-fractionation plus boost, and 6.6 % received accelerated partial breast irradiation. A shift toward increased use of hypo-fractionated regimens was noted over the three year period of this study. There were no device-related complications or cancer recurrences in this group of patients. CONCLUSIONS This study demonstrated the use of a novel 3-dimensional marker as a safe and effective method for delineating the tumor bed with a significant utility for RT planning. With routine use of the device, an increased use of hypofractionation with a resultant 25 % cost savings was noted.
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Seven-Year Outcomes Following Accelerated Partial Breast Irradiation Stratified by ASTRO Consensus Groupings. Am J Clin Oncol 2017; 40:483-489. [PMID: 25844825 DOI: 10.1097/coc.0000000000000190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Limited long-term data exist regarding outcomes for patients treated with accelerated partial breast irradiation (APBI), particularly, when stratified by American Society for Radiation Oncology (ASTRO) Consensus Statement (CS) risk groups. The purpose of this analysis is to present 5- and 7-year outcomes following APBI based on CS groupings. MATERIALS AND METHODS A total of 690 patients with early-stage breast cancer underwent APBI from 1993 to 2012, receiving interstitial brachytherapy (n=195), balloon-based brachytherapy (n=290), or 3-dimensional conformal radiotherapy (n=205) at a single institution. Patients were stratified into suitable, cautionary, and unsuitable groups with 5-year outcomes analyzed. Seven-year outcomes were analyzed for a subset with follow-up of ≥2 years (n=625). RESULTS Median follow-up was 6.7 years (range, 0.1 to 20.1 y). Patients assigned to cautionary and unsuitable categories were more likely to have high-grade tumors (21% to 25% vs. 9%, P=0.001), receive chemotherapy (15% to 38% vs. 6%, P<0.001), and have close/positive margins (9% to 11% vs. 0%, P<0.001). There was no difference in ipsilateral breast tumor recurrence at 5 or 7 years: 2.2%, 1.2%, 2.8% at 5 years (P=0.57), and 2.2%, 1.9%, 4.6% at 7 years (P=0.58) in the suitable, cautionary, and unsuitable groups, respectively. As compared with the suitable group, increased rates of distant metastases were noted for the unsuitable and cautionary groups at 5 years (P=0.04). CONCLUSIONS No differences in rates of ipsilateral breast tumor recurrence were seen at 5 or 7 years when stratified by ASTRO CS groupings. Modest increases in distant recurrence were noted in the cautionary and unsuitable groups. These findings suggest that the ASTRO CS groupings stratify more for systemic recurrence and may not appropriately select patients for whole versus partial breast irradiation.
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Pérez M, Schootman M, Hall LE, Jeffe DB. Accelerated partial breast irradiation compared with whole breast radiation therapy: a breast cancer cohort study measuring change in radiation side-effects severity and quality of life. Breast Cancer Res Treat 2017; 162:329-342. [PMID: 28132391 PMCID: PMC5374079 DOI: 10.1007/s10549-017-4121-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/18/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Radiotherapy (RT) after breast-conserving surgery for early-stage breast cancer patients has similar survival benefits with whole breast RT (WBRT) or accelerated partial breast irradiation (APBI). However, the impact of RT type and side-effects severity on change in quality of life (QOL) is unknown. We examined changes in RT side-effects severity and QOL by RT type. METHODS We analyzed data from a cohort of 285 newly diagnosed early-stage breast cancer patients with tumor size ≤3.0 cm and lymph node-negative disease. Patients (93 [32.6%] stage 0; 49 [17.2%] non-white; mean age = 59.3 years) completed four interviews (6 weeks, 6, 12, and 24 months) after definitive surgical treatment. We measured severity of RT side effects, fatigue and skin irritation, using a 5-point scale (1 "not at all" to 5 "all the time") and measured QOL using the Functional Assessment of Cancer Therapy-Breast (FACT-B) and RAND 36-item Health Survey Vitality subscale. Repeated-measures analysis of covariance of each outcome controlled for demographic, clinical/treatment, and psychosocial factors. RESULTS Patients initiated RT by 6 months (113 received APBI; 172 received WBRT) and completed RT by 12 months. Patients receiving WBRT (vs. APBI) reported greater increase in fatigue and skin irritation severity from 6-week to 6-month interviews (each P < 0.001). Improvement in neither total FACT-B nor Vitality differed significantly by RT type over 2-year follow-up. CONCLUSIONS Findings suggest that early-stage breast cancer patients can benefit from less-severe, short-term side effects of APBI with no differential impact on QOL change within 2-year follow-up.
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Affiliation(s)
- M Pérez
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - M Schootman
- Saint Louis University College for Public Health and Social Justice, St. Louis, Missouri, USA
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
| | - L E Hall
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - D B Jeffe
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
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Arthur DW, Winter KA, Kuerer HM, Haffty BG, Cuttino LW, Todor DA, Simone NL, Hayes SB, Woodward WA, McCormick B, Cohen RJ, Sahijdak WM, Canaday DJ, Brown DR, Currey AD, Fisher CM, Jagsi R, White J. NRG Oncology-Radiation Therapy Oncology Group Study 1014: 1-Year Toxicity Report From a Phase 2 Study of Repeat Breast-Preserving Surgery and 3-Dimensional Conformal Partial-Breast Reirradiation for In-Breast Recurrence. Int J Radiat Oncol Biol Phys 2017; 98:1028-1035. [PMID: 28721885 DOI: 10.1016/j.ijrobp.2017.03.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 03/01/2017] [Accepted: 03/10/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the associated toxicity, tolerance, and safety of partial-breast reirradiation. METHODS AND MATERIALS Eligibility criteria included in-breast recurrence occurring >1 year after whole-breast irradiation, <3 cm, unifocal, and resected with negative margins. Partial-breast reirradiation was targeted to the surgical cavity plus 1.5 cm; a prescription dose of 45 Gy in 1.5 Gy twice daily for 30 treatments was used. The primary objective was to evaluate the rate of grade ≥3 treatment-related skin, fibrosis, and/or breast pain adverse events (AEs), occurring ≤1 year from re-treatment completion. A rate of ≥13% for these AEs in a cohort of 55 patients was determined to be unacceptable (86% power, 1-sided α = 0.07). RESULTS Between 2010 and 2013, 65 patients were accrued, and the first 55 eligible and with 1 year follow-up were analyzed. Median age was 68 years. Twenty-two patients had ductal carcinoma in situ, and 33 had invasive disease: 19 ≤1 cm, 13 >1 to ≤2 cm, and 1 >2 cm. All patients were clinically node negative. Systemic therapy was delivered in 51%. All treatment plans underwent quality review for contouring accuracy and dosimetric compliance. All treatment plans scored acceptable for tumor volume contouring and tumor volume dose-volume analysis. Only 4 (7%) scored unacceptable for organs at risk contouring and organs at risk dose-volume analysis. Treatment-related skin, fibrosis, and/or breast pain AEs were recorded as grade 1 in 64% and grade 2 in 7%, with only 1 (<2%) grade ≥3 and identified as grade 3 fibrosis of deep connective tissue. CONCLUSION Partial-breast reirradiation with 3-dimensional conformal radiation therapy after second lumpectomy for patients experiencing in-breast failures after whole-breast irradiation is safe and feasible, with acceptable treatment quality achieved. Skin, fibrosis, and breast pain toxicity was acceptable, and grade 3 toxicity was rare.
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Affiliation(s)
- Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia.
| | - Kathryn A Winter
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Laurie W Cuttino
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Dorin A Todor
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Nicole L Simone
- Department of Radiation Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Wendy A Woodward
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Randi J Cohen
- Department of Radiation Oncology, University of Maryland Medical System, Baltimore, Maryland
| | - Walter M Sahijdak
- Department of Radiation Oncology, Michigan Cancer Research Consortium Community Clinical Oncology Program, Ann Arbor, Michigan
| | | | - Doris R Brown
- Department of Radiation Oncology, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Adam D Currey
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christine M Fisher
- Department of Radiation Oncology, University of Colorado Denver, Denver, Colorado
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Julia White
- Department of Radiation Oncology, Ohio State University, Columbus, Ohio
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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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Shaitelman SF, Chiang YJ, Griffin KD, DeSnyder SM, Smith BD, Schaverien MV, Woodward WA, Cormier JN. Radiation therapy targets and the risk of breast cancer-related lymphedema: a systematic review and network meta-analysis. Breast Cancer Res Treat 2016; 162:201-215. [PMID: 28012086 DOI: 10.1007/s10549-016-4089-0] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/16/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE New indications have been found for regional nodal irradiation (RNI) in breast cancer treatment, yet the relationship of RNI and lymphedema risk is uncertain. We sought to determine the association of RNI and lymphedema. METHODS We searched MEDLINE, EMBASE, and Scopus for articles in English on humans published from 1995 to 2015, using search terms breast neoplasm, treatment, and morbidity. Two investigators independently selected articles and extracted information, including manuscripts reporting incidence of lymphedema by radiation targets. Meta-analyses, review papers, case-control studies, matched-pair studies, repetitive datasets, and retrospective studies were excluded. A total of 2399 abstracts were identified and 323 corresponding articles reviewed. Twenty-one studies met inclusion criteria. Data were pooled using a random effects mixed model. Network meta-analyses were performed to determine the association of radiation targets alone and radiation targets plus extent of axillary surgery on incidence of lymphedema. RESULTS The addition of RNI to breast/CW irradiation was associated with an increased incidence of lymphedema (OR 2.85; 95% CI 1.24-6.55). In patients treated with sentinel lymph node biopsy or axillary sampling, there was no association of lymphedema with the addition of RNI to breast/CW irradiation (OR 1.58; 95% CI 0.54-4.66; pooled incidence 5.7 and 4.1%, respectively). Among patients treated with axillary lymph node dissection (ALND), treatment with RNI in addition to breast/CW radiation was associated with a significantly higher risk of lymphedema (OR 2.74; 95% CI 1.38-5.44; pooled incidence 18.2 and 9.4%, respectively). CONCLUSIONS RNI is associated with a significantly higher risk of lymphedema than irradiation of the breast/CW, particularly after ALND.
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Affiliation(s)
- Simona F Shaitelman
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1202, Houston, TX, 77030, USA.
| | - Yi-Ju Chiang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
| | - Kate D Griffin
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
| | - Sarah M DeSnyder
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1434, Houston, TX, 77030, USA
| | - Benjamin D Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1202, Houston, TX, 77030, USA
| | - Mark V Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1488, Houston, TX, 77030, USA
| | - Wendy A Woodward
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1202, Houston, TX, 77030, USA
| | - Janice N Cormier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1484, Houston, TX, 77030, USA
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20
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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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21
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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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Strut-based accelerated partial breast irradiation: Report of treatment results for 250 consecutive patients at 5 years from a multicenter retrospective study. Brachytherapy 2016; 15:780-787. [DOI: 10.1016/j.brachy.2016.07.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 12/13/2022]
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23
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Tann AW, Hatch SS, Joyner MM, Wiederhold LR, Swanson TA. Accelerated partial breast irradiation: Past, present, and future. World J Clin Oncol 2016; 7:370-379. [PMID: 27777879 PMCID: PMC5056328 DOI: 10.5306/wjco.v7.i5.370] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/01/2016] [Accepted: 08/18/2016] [Indexed: 02/06/2023] Open
Abstract
Accelerated partial breast irradiation (APBI) focuses higher doses of radiation during a shorter interval to the lumpectomy cavity, in the setting of breast conserving therapy for early stage breast cancer. The utilization of APBI has increased in the past decade because of the shorter treatment schedule and a growing body of outcome data showing positive cosmetic outcomes and high local control rates in selected patients undergoing breast conserving therapy. Technological advances in various APBI modalities, including intracavitary and interstitial brachytherapy, intraoperative radiation therapy, and external beam radiation therapy, have made APBI more accessible in the community. Results of early APBI trials served as the basis for the current consensus guidelines, and multiple prospective randomized clinical trials are currently ongoing. The pending long term results of these trials will help us identify optimal candidates that can benefit from ABPI. Here we provide an overview of the clinical and cosmetic outcomes of various APBI techniques and review the current guidelines for selecting suitable breast cancer patients. We also discuss the impact of APBI on the economics of cancer care and patient reported quality of life.
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Brachytherapy-based Accelerated Partial Breast Irradiation Provides Equivalent 10-Year Outcomes to Whole Breast Irradiation. Am J Clin Oncol 2016; 39:468-72. [DOI: 10.1097/coc.0000000000000082] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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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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26
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Vicini F, Shah C, Tendulkar R, Wobb J, Arthur D, Khan A, Wazer D, Keisch M. Accelerated partial breast irradiation: An update on published Level I evidence. Brachytherapy 2016; 15:607-15. [DOI: 10.1016/j.brachy.2016.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 05/18/2016] [Accepted: 06/15/2016] [Indexed: 01/19/2023]
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Shah C, Tendulkar R, Smile T, Nanavati A, Manyam B, Balagamwala E, Pham Y, Takiar R, Wobb J, Khan A, Arthur D, Wazer D, Vicini F. Adjuvant Radiotherapy in Early-Stage Breast Cancer: Evidence-Based Options. Ann Surg Oncol 2016; 23:3880-3890. [DOI: 10.1245/s10434-016-5503-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Indexed: 01/22/2023]
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28
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Hennequin C, Guillerm S, Quero L. [Not Available]. Bull Cancer 2016; 103:S99-S104. [PMID: 27494982 DOI: 10.1016/s0007-4551(16)30153-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
DE-ESCALATION OF RADIOTHERAPY OF INFILTRATING BREAST CANCER WHERE CAN WE GO?: Adjuvant radiotherapy (RT) has an important role in the management of infiltrating breast cancer, not only to improve local control but also overall survival. So, all attempt of de-escalation must be performed in the context of large prospective studies. However, RT could induce some complications and last 5 to 7 weeks. Three ways of RT de-escalation have been studied.
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Affiliation(s)
| | - Sophie Guillerm
- Service de cancérologie-radiothérapie, Hôpital Saint-Louis, Paris
| | - Laurent Quero
- Service de cancérologie-radiothérapie, Hôpital Saint-Louis, Paris
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29
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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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30
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Shah C, Berry S. Accelerated partial breast irradiation: a review and evaluation of indications for treatment. BREAST CANCER MANAGEMENT 2015. [DOI: 10.2217/bmt.15.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Accelerated partial breast irradiation (APBI) represents a well-studied treatment modality for the delivery of adjuvant radiation therapy following breast-conserving surgery. Interstitial APBI represents the APBI technique with the longest follow-up to date; data from randomized trials and matched pair analyses demonstrate equivalent local control to traditional whole-breast irradiation with comparable rates of toxicity and improved cosmesis. While less mature, prospective data support the efficacy and safety of applicator-based brachytherapy with new multilumen applicators offering the potential for improved outcomes. External beam APBI represents a noninvasive technique; however, concerns regarding toxicity with this technique have emerged though newer techniques may mitigate these concerns. Multiple guidelines have been published based on traditional clinical and pathologic criteria to help physicians offer APBI to appropriately selected patients.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Mail Code T28, Cleveland, OH, USA
| | - Sameer Berry
- Department of Radiation Oncology, Taussig Cancer institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Mail Code T28, Cleveland, OH, USA
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Riou O, Fenoglietto P, Bourgier C, Lauche O, Boulbair F, Charissoux M, Ducteil A, Aillères N, Lemanski C, Azria D. Feasibility of accelerated partial breast irradiation with volumetric-modulated arc therapy in elderly and frail patients. Radiat Oncol 2015; 10:209. [PMID: 26466672 PMCID: PMC4606890 DOI: 10.1186/s13014-015-0516-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 10/06/2015] [Indexed: 01/27/2023] Open
Abstract
Background Accelerated partial breast irradiation (APBI) is an option for adjuvant radiotherapy according to ASTRO and ESTRO recommendations. Among the available techniques, volumetric-modulated arc therapy (VMAT) is attractive but has not been extensively studied for APBI. This study assessed its feasibility, tolerance and early oncological outcomes. Methods We analysed the data of nine patients (median age 74 years) with ten lesions (one bilateral cancer) treated from May 2011 to July 2012 with APBI using VMAT. The radiation oncologist delineated the surgical tumour bed, and added an 18 mm isotropic margin to obtain the planning target volume (PTV). The dose was 40 Gy prescribed in 4 Gy fractions given twice a day over five days. Patients were regularly followed for toxicities and oncological outcomes. Results Mean PTV was 100.0 cm3 and 95 % of the PTV received a mean dose of 99.7 % of the prescribed dose. Hot spots represented 0.3 % of the PTV. 6.2 %, 1.6 % and 0.3 % of the ipsilateral lung volume received 5 Gy (V5Gy), 10 Gy (V10Gy) and 20 Gy (V20Gy), respectively. Regarding the contralateral lung, V5Gy was 0.3 %, and V10Gy and V20Gy were nil. V5Gy accounted for 3.1 % of the heart. An average 580 monitor units were delivered. No acute or late grade ≥ 2 toxicities were observed. With a median follow-up of 26 months, no relapses occurred. Conclusion In our study, VMAT allowed optimal dosimetry with consequential high therapeutic ratio in elderly and frail patients.
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Affiliation(s)
- Olivier Riou
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Pascal Fenoglietto
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Céline Bourgier
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Olivier Lauche
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Fatiha Boulbair
- Radiotherapy Department, Mulhouse Hospital, Mulhouse, France.
| | - Marie Charissoux
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Angélique Ducteil
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Norbert Aillères
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Claire Lemanski
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - David Azria
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
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Hennequin C, Guillerm S, Quero L. [Radiotherapy in elderly patients, recommendations for the main localizations: Breast, prostate and gynaecological cancers]. Cancer Radiother 2015; 19:397-403. [PMID: 26282214 DOI: 10.1016/j.canrad.2015.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 05/21/2015] [Indexed: 11/18/2022]
Abstract
Modifications of radiotherapy indications or schedules because of age could be discussed in view of a different evolution of the disease or because of specific toxicities. One important aim is to decrease the number of hospital transports. For breast cancer, the rate of local relapse after lumpectomy is lower in old patients; moreover, characteristics of the disease are often more favourable (hormonosensitivity, low grade). However, adjuvant irradiation decreases significantly the incidence of breast relapse and must be systematically proposed. Hypofractionnated schedules must be recommended; limited data are available for accelerated partial breast irradiation in old women and these techniques must not be used in routine. For low or intermediate risk prostate cancer, assessment of comorbidities is crucial before considering any invasive treatment. A life expectancy of at least 10 years is required if a curative approach, potentially toxic is proposed. In this case, radiotherapy is often the good choice, giving less sequelae than surgery. The indication of androgen deprivation must take into account cardiovascular and bone history. Management of gynaecological cancers must follow the same recommendations as in young women. Exclusive postoperative brachytherapy must be recommended in early stage endometrial carcinomas. Brachytherapy must be also systematically integrated in the radiotherapy program for cervix cancers, even in old women.
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Affiliation(s)
- C Hennequin
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefeaux, 75475 Paris, France; Université Paris Diderot, 1, avenue Claude-Vellefeaux, 75475 Paris, France.
| | - S Guillerm
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefeaux, 75475 Paris, France; Université Paris Diderot, 1, avenue Claude-Vellefeaux, 75475 Paris, France
| | - L Quero
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefeaux, 75475 Paris, France; Université Paris Diderot, 1, avenue Claude-Vellefeaux, 75475 Paris, France
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Galland-Girodet S, Pashtan I, MacDonald SM, Ancukiewicz M, Hirsch AE, Kachnic LA, Specht M, Gadd M, Smith BL, Powell SN, Recht A, Taghian AG. Long-term cosmetic outcomes and toxicities of proton beam therapy compared with photon-based 3-dimensional conformal accelerated partial-breast irradiation: a phase 1 trial. Int J Radiat Oncol Biol Phys 2014; 90:493-500. [PMID: 24880212 DOI: 10.1016/j.ijrobp.2014.04.008] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/04/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To present long-term outcomes of a prospective feasibility trial using either protons or 3-dimensional conformal photon-based (accelerated partial-breast irradiation [APBI]) techniques. METHODS AND MATERIALS From October 2003 to April 2006, 98 evaluable patients with stage I breast cancer were treated with APBI (32 Gy in 8 fractions given twice daily) on a prospective clinical trial: 19 with proton beam therapy (PBT) and 79 with photons or mixed photons/electrons. Median follow-up was 82.5 months (range, 2-104 months). Toxicity and patient satisfaction evaluations were performed at each visit. RESULTS At 7 years, the physician rating of overall cosmesis was good or excellent for 62% of PBT patients, compared with 94% for photon patients (P=.03). Skin toxicities were more common for the PBT group: telangiectasia, 69% and 16% (P=.0013); pigmentation changes, 54% and 22% (P=.02); and other late skin toxicities, 62% and 18% (P=.029) for PBT and photons, respectively. There were no significant differences between the groups in the incidences of breast pain, edema, fibrosis, fat necrosis, skin desquamation, and rib pain or fracture. Patient-reported cosmetic outcomes at 7 years were good or excellent for 92% and 96% of PBT and photon patients, respectively (P=.95). Overall patient satisfaction was 93% for the entire cohort. The 7-year local failure rate for all patients was 6%, with 3 local recurrences in the PBT group (7-year rate, 11%) and 2 in photon-treated patients (4%) (P=.22). CONCLUSIONS Local failure rates of 3-dimensional APBI and PBT were similar in this study. However, PBT, as delivered in this study, led to higher rates of long-term telangiectasia, skin color changes, and skin toxicities. We recommend the use of multiple fields and treatment of all fields per treatment session or the use of scanning techniques to minimize skin toxicity.
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Affiliation(s)
| | - Itai Pashtan
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Marek Ancukiewicz
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ariel E Hirsch
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Lisa A Kachnic
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Michelle Specht
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michele Gadd
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Barbara L Smith
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Simon N Powell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
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Abstract
Local therapies to treat newly diagnosed breast cancer include a lumpectomy with radiation therapy or a mastectomy. The 20-year data from studies about the safety and efficacy of lumpectomy with full-breast radiation therapy support the safety of this regimen and its role to decrease the risk of ipsilateral recurrence and increase long-term survivorship of women with breast cancer. Accelerated partial breast irradiation (APBI) provides radiation therapy to the tumor bed but spares the remaining breast tissue. APBI accelerates the time required to complete the therapy regimen, with a range of one intraoperative session to five consecutive days compared to five to seven weeks. Several techniques exist to administer APBI, including the insertion of a balloon into the lumpectomy space. Of interest is the widespread use of APBI in community and academic settings that has preceded outcomes of large, randomized clinical trials. Because of selection bias in a number of small, single-institution, nonrandomized studies, published data are of limited value to ensure APBI as a standard of care.
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Affiliation(s)
- Elfrida Bauer
- Division of Radiation Oncology, Anderson Cancer Center at Presbyterian, Albuquerque, NM
| | - Joanne L Lester
- Department of Psychology, The Ohio State University in Columbus
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Mózsa E, Mészáros N, Major T, Fröhlich G, Stelczer G, Sulyok Z, Fodor J, Polgár C. Accelerated partial breast irradiation with external beam three-dimensional conformal radiotherapy. Strahlenther Onkol 2014; 190:444-50. [DOI: 10.1007/s00066-014-0633-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 02/05/2014] [Indexed: 01/03/2023]
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36
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Liss AL, Ben-David MA, Jagsi R, Hayman JA, Griffith KA, Moran JM, Marsh RB, Pierce LJ. Decline of cosmetic outcomes following accelerated partial breast irradiation using intensity modulated radiation therapy: results of a single-institution prospective clinical trial. Int J Radiat Oncol Biol Phys 2014; 89:96-102. [PMID: 24613813 DOI: 10.1016/j.ijrobp.2014.01.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/04/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE To report the final cosmetic results from a single-arm prospective clinical trial evaluating accelerated partial breast irradiation (APBI) using intensity modulated radiation therapy (IMRT) with active-breathing control (ABC). METHODS AND MATERIALS Women older than 40 with breast cancer stages 0-I who received breast-conserving surgery were enrolled in an institutional review board-approved prospective study evaluating APBI using IMRT administered with deep inspiration breath-hold. Patients received 38.5 Gy in 3.85-Gy fractions given twice daily over 5 consecutive days. The planning target volume was defined as the lumpectomy cavity with a 1.5-cm margin. Cosmesis was scored on a 4-category scale by the treating physician. Toxicity was scored according to National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 3.0). We report the cosmetic and toxicity results at a median follow-up of 5 years. RESULTS A total of 34 patients were enrolled. Two patients were excluded because of fair baseline cosmesis. The trial was terminated early because fair/poor cosmesis developed in 7 of 32 women at a median follow-up of 2.5 years. At a median follow-up of 5 years, further decline in the cosmetic outcome was observed in 5 women. Cosmesis at the time of last assessment was 43.3% excellent, 30% good, 20% fair, and 6.7% poor. Fibrosis according to CTCAE at last assessment was 3.3% grade 2 toxicity and 0% grade 3 toxicity. There was no correlation of CTCAE grade 2 or greater fibrosis with cosmesis. The 5-year rate of local control was 97% for all 34 patients initially enrolled. CONCLUSIONS In this prospective trial with 5-year median follow-up, we observed an excellent rate of tumor control using IMRT-planned APBI. Cosmetic outcomes, however, continued to decline, with 26.7% of women having a fair to poor cosmetic result. These results underscore the need for continued cosmetic assessment for patients treated with APBI by technique.
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MESH Headings
- Adult
- Aged
- Breast/pathology
- Breast/radiation effects
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Breath Holding
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Dose Fractionation, Radiation
- Early Termination of Clinical Trials
- Esthetics
- Female
- Fibrosis
- Follow-Up Studies
- Humans
- Middle Aged
- Movement
- Prospective Studies
- Radiation Injuries/pathology
- Radiotherapy, Intensity-Modulated/adverse effects
- Radiotherapy, Intensity-Modulated/methods
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Affiliation(s)
- Adam L Liss
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Merav A Ben-David
- Department of Radiation Oncology, The Sheba Medical Center, Ramat Gan, Israel
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Biostatistics Unit, University of Michigan, Ann Arbor, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Robin B Marsh
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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37
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[Partial breast irradiation]. Bull Cancer 2014; 101:52-5. [PMID: 24445657 DOI: 10.1684/bdc.2013.1869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Owing to breast cancer screening, breast cancer is more and more diagnosed at early stage. For those breast cancer women, breast conserving treatment (breast conserving surgery followed by whole breast irradiation) is commonly used since many years. New radiation modalities have been recently developed in early breast cancers particularly accelerated partial breast irradiation (APBI). Among all techniques of radiotherapy, 3D-conformal APBI and intraoperative radiotherapy (IORT) are the main modalities of radiotherapy used. The present review states on indications, treatment modalities and updated results of local control and side effects of partial breast irradiation.
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Five-Year Outcomes, Cosmesis, and Toxicity With 3-Dimensional Conformal External Beam Radiation Therapy to Deliver Accelerated Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2013; 87:1051-7. [DOI: 10.1016/j.ijrobp.2013.08.046] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/12/2013] [Accepted: 08/27/2013] [Indexed: 01/29/2023]
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