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Gimeno-Morales M, Martínez-Monge R, Martinez-Lage A, Jablonska PA, Blanco J, Martínez-Regueira F, Rodriguez-Spiteri N, Olartecoechea B, Ramos L, Insausti LP, Elizalde A, Abengozar M, Cambeiro M. Long-term results of intraoperative multicatheter breast implant (IOMBI) for accelerated partial breast irradiation (APBI) on early breast cancer patients. Radiother Oncol 2024; 194:110193. [PMID: 38432310 DOI: 10.1016/j.radonc.2024.110193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 02/12/2024] [Accepted: 02/24/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND AND PURPOSE Multicatheter breast brachytherapy is a standard technique for accelerated partial breast irradiation (APBI) in early breast cancer patients. Intraoperative multicatheter breast implant (IOMBI) followed by perioperative high-dose-rate brachytherapy (PHDRBT) offers a novel and advantageous approach. We present long-term oncological, toxicity, and cosmesis outcomes for a well-experienced single institution. MATERIALS AND METHODS Eligible women aged ≥ 40 years with clinically and radiologically confirmed unifocal invasive or in situ ≤ 3 cm breast tumors underwent IOMBI during breast-conserving surgery. Patients meeting APBI criteria by definitive pathologic results received 3.4 Gy × 10fx with PHDRBT. Patients not suitable for APBI received PHDRBT-boost followed by WBRT. RESULTS A total of 171 patients underwent IOMBI during BCS, 120 patients (70.1 %) were suitable for APBI and 51 (29.8 %) for anticipated PHDRBT-boost. The median age was 61 years (range: 40-78), the median tumor size was 1.1 cm (range: 0.2-3.5), with a histological diagnosis of invasive ductal carcinoma in 78.9 % and ductal in situ in 21.1 %. A median of 9 catheters (range: 4-14) were used. For APBI, the median CTV and V100 were 40.8 cc (range: 8.6-99) and 35.4 cc (range: 7.2-94). The median of healthy breast tissue irradiated represents 7.2 % (range: 2.3-28 %) and the median local treatment duration was 10 days (range: 7-16). With a median follow-up of 8.8 years (range: 0.3-16.25), the 8-year local, locoregional, and distant control rates were 99 %, 98.1 %, and 100 %. G1-G2 late-toxicity rate was 53.4 %. Long-term cosmetic evaluation was excellent-good in 90.8 %. CONCLUSION IOMBI&PHDRBT program reports excellent long-term oncological outcomes, with a reduction from unnecessary irradiation exposure which translates into low long-term toxicity and good cosmesis outcomes, especially on well-selected APBI patients.
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Affiliation(s)
- Marta Gimeno-Morales
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain.
| | - Rafael Martínez-Monge
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Adriana Martinez-Lage
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Paola Anna Jablonska
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Javier Blanco
- Medical Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Fernando Martínez-Regueira
- Breast Surgical Oncology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Natalia Rodriguez-Spiteri
- Breast Surgical Oncology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Begoña Olartecoechea
- Breast Surgical Oncology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Luis Ramos
- Departament of Medical Physic, Hospital Arnau de Villanova, Lleida, Spain
| | - Luis Pina Insausti
- Radiology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Arlette Elizalde
- Radiology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Marta Abengozar
- Pathology Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
| | - Mauricio Cambeiro
- Departments of Radiation Oncology, Cancer Center Clinica Universidad de Navarra. University of Navarre. Pamplona-Madrid, Spain
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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: 0] [Impact Index Per Article: 0] [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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Shumway DA, Corbin KS, Farah MH, Viola KE, Nayfeh T, Saadi S, Shah V, Hasan B, Shah S, Mohammed K, Riaz IB, Prokop LJ, Murad MH, Wang Z. Partial breast irradiation compared with whole breast irradiation: a systematic review and meta-analysis. J Natl Cancer Inst 2023; 115:1011-1019. [PMID: 37289549 PMCID: PMC10483267 DOI: 10.1093/jnci/djad100] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Early-stage breast cancer is among the most common cancer diagnoses. Adjuvant radiotherapy is an essential component of breast-conserving therapy, and several options exist for tailoring its extent and duration. This study assesses the comparative effectiveness of partial-breast irradiation (PBI) compared with whole-breast irradiation (WBI). METHODS A systematic review was completed to identify relevant randomized clinical trials and comparative observational studies. Independent reviewers working in pairs selected studies and extracted data. Randomized trial results were pooled using a random effects model. Prespecified main outcomes were ipsilateral breast recurrence (IBR), cosmesis, and adverse events (AEs). RESULTS Fourteen randomized clinical trials and 6 comparative observational studies with 17 234 patients evaluated the comparative effectiveness of PBI. PBI was not statistically significantly different from WBI for IBR at 5 years (RR = 1.34, 95% CI = 0.83 to 2.18; high strength of evidence [SOE]) and 10 years (RR = 1.29, 95% CI = 0.87 to 1.91; high SOE). Evidence for cosmetic outcomes was insufficient. Statistically significantly fewer acute AEs were reported with PBI compared with WBI, with no statistically significant difference in late AEs. Data from subgroups according to patient, tumor, and treatment characteristics were insufficient. Intraoperative radiotherapy was associated with higher IBR at 5, 10, and over than 10 years (high SOE) compared with WBI. CONCLUSIONS Ipsilateral breast recurrence was not statistically significantly different between PBI and WBI. Acute AEs were less frequent with PBI. This evidence supports the effectiveness of PBI among selected patients with early-stage, favorable-risk breast cancer who are similar to those represented in the included studies.
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Affiliation(s)
- Dean A Shumway
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Kimberly S Corbin
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Magdoleen H Farah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kelly E Viola
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Samer Saadi
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Vishal Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Bashar Hasan
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Sahrish Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Khaled Mohammed
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Irbaz Bin Riaz
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
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Ott OJ, Stillkrieg W, Lambrecht U, Schweizer C, Lamrani A, Sauer TO, Strnad V, Bert C, Hack CC, Beckmann MW, Fietkau R. External-Beam-Accelerated Partial-Breast Irradiation Reduces Organ-at-Risk Doses Compared to Whole-Breast Irradiation after Breast-Conserving Surgery. Cancers (Basel) 2023; 15:3128. [PMID: 37370738 DOI: 10.3390/cancers15123128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
In order to evaluate organ-at-risk (OAR) doses in external-beam-accelerated partial-breast irradiation (APBI) compared to standard whole-breast irradiation (WBI) after breast-conserving surgery. Between 2011 and 2021, 170 patients with early breast cancer received APBI within a prospective institutional single-arm trial. The prescribed dose to the planning treatment volume was 38 Gy in 10 fractions on 10 consecutive working days. OAR doses for the contralateral breast, the ipsilateral, contralateral, and whole lung, the whole heart, left ventricle (LV), and the left anterior descending coronary artery (LAD), and for the spinal cord and the skin were assessed and compared to a control group with real-world data from 116 patients who underwent WBI. The trial was registered at the German Clinical Trials Registry, DRKS-ID: DRKS00004417. Compared to WBI, APBI led to reduced OAR doses for the contralateral breast (0.4 ± 0.6 vs. 0.8 ± 0.9 Gy, p = 0.000), the ipsilateral (4.3 ± 1.4 vs. 9.2 ± 2.5 Gy, p = 0.000) and whole mean lung dose (2.5 ± 0.8 vs. 4.9 ± 1.5 Gy, p = 0.000), the mean heart dose (1.6 ± 1.6 vs. 1.7 ± 1.4 Gy, p = 0.007), the LV V23 (0.1 ± 0.4 vs. 1.4 ± 2.6%, p < 0.001), the mean LAD dose (2.5 ± 3.4 vs. 4.8 ± 5.5 Gy, p < 0.001), the maximum spinal cord dose (1.5 ± 1.1 vs. 4.5 ± 5.7 Gy, p = 0.016), and the maximum skin dose (39.6 ± 1.8 vs. 49.1 ± 5.8 Gy, p = 0.000). APBI should be recommended to suitable patients to minimize the risk of secondary tumor induction and the incidence of consecutive major cardiac events.
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Affiliation(s)
- Oliver J Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Wilhelm Stillkrieg
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Ulrike Lambrecht
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Claudia Schweizer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Allison Lamrani
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Tim-Oliver Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Carolin C Hack
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
- Department of Gynecology and Obstetrics, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Matthias W Beckmann
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
- Department of Gynecology and Obstetrics, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
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Squeo GC, Meneveau MO, Varhegyi NE, Lattimore CM, Janowski E, Showalter TN, Showalter SL. Factors Associated With Cosmetic Outcomes After Treatment With a Novel Form of Breast Intraoperative Radiation Therapy. J Surg Res 2023; 283:514-522. [PMID: 36436288 DOI: 10.1016/j.jss.2022.10.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 09/07/2022] [Accepted: 10/15/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Precision breast intraoperative radiation therapy (PB-IORT) incorporates computed tomography-guided treatment planning and high dose rate brachytherapy to deliver a single dose of highly conformal radiational therapy. The purpose of this study is to determine factors associated with poor cosmetic outcomes after treatment with PB-IORT. METHODS The study included all consecutive participants enrolled in an ongoing phase II clinical trial that had completed a minimum of 12 mo of follow-up. A poor cosmetic outcome was defined as scoring "fair" or "poor" on the Harvard Cosmesis evaluation, or "some" or "very much" on any of the three general cosmesis categories. Statistical analysis was performed utilizing R. RESULTS The final cohort included 201 participants, of which 181 (90%) had an overall good/excellent cosmetic outcome. Group 1 consisted of 162 (81%) participants who reported only excellent/good cosmetic outcomes. Group 2 consisted of 39 (19%) participants who reported some aspect of a poor cosmetic outcome. On multivariable analysis, participants with ductal carcinoma in situ were significantly more likely to experience a poor cosmetic outcome (odds ratio 2.45, 95% confidence interval 1.03-5.82, P = 0.04), and those who received subsequent whole breast irradiation were also more likely to have a poor cosmetic outcome (odds ratio 10.20, 95% confidence interval CI 1.04-99.95, P = 0.04). CONCLUSIONS Patients with need for further radiation after PB-IORT are at increased risk for a poor cosmetic outcome. Larger balloon volume and distance between the skin do not have deleterious effects on cosmetic outcomes.
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Affiliation(s)
- Gabriella C Squeo
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia
| | - Max O Meneveau
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia
| | - Nikole E Varhegyi
- University of Virginia School of Medicine, Department of Public Health Sciences, Charlottesville, Virginia
| | - Courtney M Lattimore
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia
| | - Einsley Janowski
- University of Virginia School of Medicine, Department of Radiation Oncology, Charlottesville, Virginia
| | - Timothy N Showalter
- University of Virginia School of Medicine, Department of Radiation Oncology, Charlottesville, Virginia
| | - Shayna L Showalter
- University of Virginia School of Medicine, Department of Surgery, Charlottesville, Virginia.
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Volume matters: Breast induration is associated with irradiated breast volume in the Danish Breast Cancer Group phase III randomized Partial Breast Irradiation trial. Radiother Oncol 2022; 177:231-235. [PMID: 36265685 DOI: 10.1016/j.radonc.2022.09.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/22/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The relation between breast induration grade 2-3 at 3 years after radiation therapy and irradiated breast volume was investigated for patients in the Danish Breast Cancer Group (DBCG) Partial Breast Irradiation (PBI) trial. METHODS Treatment plan data was obtained from the Danish radiotherapy plan database. Dosimetric parameters for breast and organs at risk were determined. Breast induration data was obtained from the DBCG database. The volume of the whole breast (CTVp_breast) treated to various dose levels was determined for treatment plans in both arms. Logistic regression was used to assess the frequency of induration on breast volume irradiated to ≥40 Gy. RESULTS PBI and WBI was given to 433 and 432 patients, respectively. Median and interquartile ranges (IQR) for CTVp_breast were 710 mL (467-963 mL; PBI) and 666 mL (443-1012 mL; WBI) (p = 0.98). Median and IQR for CTVp_breast treated to ≥40 Gy was 24.9% (18.6-32.6%; PBI) and 59.8% (53.6-68.5%; WBI). Grade 2-3 induration was observed in 5% (PBI) and 10% (WBI) of the patients. A dose-response relationship was established between irradiated breast volume and frequency of breast induration. From the model, 5% and 10% risks of breast induration were observed for ≥40 Gy delivered to CTVp_breast volumes of 177 mL (95%CI, 94-260 mL) and 426 mL (95%CI, 286-567 mL), respectively. CONCLUSION The frequency of breast induration increased significantly with increasing irradiated breast volume, strongly favouring small volumes and PBI. Thus, treated breast volume - not the breast size itself - is the risk factor for induration. This is the first report directly linking the 40 Gy irradiated breast volume to breast induration.
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Anderson B, Arthur D, Hannoun-Levi JM, Kamrava M, Khan A, Kuske R, Scanderbeg D, Shah C, Shaitelman S, Showalter T, Vicini F, Wazer D, Yashar C. Partial breast irradiation: An updated consensus statement from the American brachytherapy society. Brachytherapy 2022; 21:726-747. [PMID: 36117086 DOI: 10.1016/j.brachy.2022.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques. METHODS Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed. RESULTS The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion. CONCLUSIONS This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | | | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Simona Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
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8
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Ciunkiewicz P, Roumeliotis M, Stenhouse K, McGeachy P, Quirk S, Grendarova P, Yanushkevich S. Assessment of Tissue Toxicity Risk in Breast Radiotherapy using Bayesian Networks. Med Phys 2022; 49:3585-3596. [PMID: 35442533 DOI: 10.1002/mp.15651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/19/2022] [Accepted: 03/23/2022] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The purpose of this analysis is to predict worsening post-treatment normal tissue toxicity in patients undergoing accelerated partial breast irradiation (APBI) therapy and to quantitatively identify which diagnostic, anatomical, and dosimetric features are contributing to these outcomes. METHODS A retrospective study of APBI treatments was performed using 32 features pertaining to various stages of the patient's treatment journey. These features were used to inform and construct a Bayesian network (BN) based on both statistical analysis of feature distributions and relative clinical importance. The target feature for prediction was defined as a measurable worsening of telangiectasia, subcutaneous tissue induration, or fibrosis when compared against the observed baseline. Parameter learning for the network was performed using data from the 299 patients included in the ACCEL trial and predictive performance was measured. Feature importance for the BN was quantified using a novel information-theoretic approach. RESULTS Cross validated performance of the BN for predicting toxicity was consistently higher when compared against conventional machine learning (ML) techniques. The measured BN receiver operating characteristic area under the curve was 0.960±0.013 against the best ML result of 0.942±0.021 using 5-fold cross validation with separate test data across 100 trials. The volume of the clinical target volume, gross target volume, and baseline toxicity measurements were found to have the highest feature importance and mutual dependence with normal tissue toxicity in the network, representing the strongest contribution to patient outcomes. CONCLUSIONS The BN outperformed conventional ML techniques in predicting tissue toxicity outcomes and provided deeper insight into which features are contributing to these outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Philip Ciunkiewicz
- University of Calgary, Biomedical Engineering, 2500 University Dr. NW, Calgary, AB, T2N1N4, Canada
| | | | | | | | - Sarah Quirk
- Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Petra Grendarova
- University of Calgary, Alberta Health Services, Calgary, AB, Canada
| | - Svetlana Yanushkevich
- University of Calgary, Biomedical Engineering, 2500 University Dr. NW, Calgary, AB, T2N1N4, Canada
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9
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Zhang-Velten E, Zhang Y, Radpour S, Gu X, Kim DN, Alluri P, Nwachukwu C, Chiu T, Lu W, Parsons D, Tan J, Gillespie J, Stevenson S, Choy H, Timmerman R, Rahimi A. A How-To Compendium for GammaPod Treatments, Clinical Workflow, and Clinical Program at an Early Adopting Institution. Pract Radiat Oncol 2022; 12:e177-e182. [PMID: 35150897 DOI: 10.1016/j.prro.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/18/2021] [Accepted: 01/18/2022] [Indexed: 11/29/2022]
Abstract
Breast irradiation following breast-conserving surgery is an integral part of breast conserving therapy for curative treatment of early-stage breast cancer1-7. With the recognition that the majority of ipsilateral local relapses following breast-conserving therapy occur at the site of the tumor bed, several trials have since investigated the efficacy of accelerated partial-breast irradiation (APBI)8-10 as an alternative to the established but less convenient option of daily whole breast irradiation over several weeks. However, the setup uncertainty and inter-fraction movement expected with 3-dimensional conformal radiation therapy (3D-CRT) APBI has generally required the use of larger planning target volume margin expansions, which ultimately results in a larger dose to normal tissues, as well as an association with worsened cosmesis11-13. A stereotactic partial breast irradiation (S-PBI) approach is needed to allow more precise radiation therapy to the region of the primary tumor. As the GammaPod uses a vacuum assisted breast cup and pump, it allows for smaller CTV margins than 3D-CRT. Here, we describe our methods and workflow for efficient GammaPod S-PBI, as the second institution in the world to go live with GammaPod.
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Affiliation(s)
- Elizabeth Zhang-Velten
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - You Zhang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sepeadeh Radpour
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Xuejun Gu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - D Nathan Kim
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Prasanna Alluri
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Chika Nwachukwu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tsuicheng Chiu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Weiguo Lu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Parsons
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jun Tan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jennifer Gillespie
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stella Stevenson
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Hak Choy
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Asal Rahimi
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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10
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Chang JS, Chang JH, Kim N, Kim YB, Shin KH, Kim K. Intensity Modulated Radiotherapy and Volumetric Modulated Arc Therapy in the Treatment of Breast Cancer: An Updated Review. J Breast Cancer 2022; 25:349-365. [DOI: 10.4048/jbc.2022.25.e37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/16/2022] [Accepted: 07/24/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Nalee Kim
- Department of Radiation Oncology, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Korea
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11
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Leonard CE, Wang Y, Asmar L, Lei RY, Howell KT, Henkenberns PL, Johnson TK, Hobart TL, Tole SP, Kercher JM, Widner JL, Barke L, Kaske T, Carter DL. A prospective Phase III trial evaluating patient self-reported pain and cosmesis in accelerated partial breast irradiation utilizing 3-D versus intensity-modulated radiotherapy. Cancer Med 2021; 10:7089-7100. [PMID: 34469056 PMCID: PMC8525102 DOI: 10.1002/cam4.4242] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/09/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose/Objective The primary objective is to examine patient self‐assessment of breast pain and cosmesis between three‐dimensional (3D‐CRT) versus intensity‐modulated radiotherapy (IMRT). The secondary objective is to evaluate any relationship of treatment planning conformality of both cohorts to patient‐assessed pain. Assessments were performed at interim 12, 24, 36, and 48 months with a final 5‐year assessment. Materials/Methods In total, 656 patients (3D‐CRT n = 328; IMRT n = 328) were randomly assigned to either IMRT or 3D‐CRT accelerated partial breast radiotherapy to 38.5 Gy in 10 BID 3.85 Gy fractions. Results Median follow‐up was 3 years. Multivariate analysis showed that pain severity significantly decreased from baseline to the 12‐month follow‐up visit (<0.001 for both 3D‐CRT and IMRT) in each cohort. There was significantly less pain at 2 (p = 0.002) and 3 years (0.045) in the IMRT arm versus the 3D‐CRT arm when compared to the baseline pain level. There was no difference in patient‐assessed cosmesis at any follow‐up point; however, although MD‐assessed cosmesis showed no difference from years 1 to 4, there was significantly better cosmesis for 3D‐CRT versus IMRT (p = 0.047) at 5 years. There was a significant correlation between a maximum pain score and an increase in the CI100 (indicating less conformity) in the IMRT cohort (p < 0.01) and in the IMRT subgroup when the CI100 was ≤0.37 cohort arm (p = 0.01). Conclusion In the analysis of our primary objective we found that at 2 years, IMRT resulted in more interval improvement in breast pain after baseline when compared to patients treated with 3D‐CRT planning. As seen in our secondary analysis, this may be due to the ability of IMRT to achieve higher conformality (as evidenced by lower CI values) resulting in less fibrosis. There were no differences in patient‐assessed cosmesis or MD‐assessed cosmesis for years 1–4; however, physician‐assessed 5‐year cosmesis was better with 3D‐CRT.
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Affiliation(s)
| | | | - Lina Asmar
- Linasmar Consulting, Houston, Texas, USA
| | - Rachel Y Lei
- Rocky Mountain Cancer Centers, Littleton, Colorado, USA
| | | | | | | | | | | | | | | | - Lora Barke
- Sally Jobe Diagnostic Breast Center, Greenwood Village, Colorado, USA
| | - Terese Kaske
- Sally Jobe Diagnostic Breast Center, Greenwood Village, Colorado, USA
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12
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Hickey BE, Lehman M. Partial breast irradiation versus whole breast radiotherapy for early breast cancer. Cochrane Database Syst Rev 2021; 8:CD007077. [PMID: 34459500 PMCID: PMC8406917 DOI: 10.1002/14651858.cd007077.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane Review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)). OBJECTIVES To determine whether PBI/APBI is equivalent to or better than conventional or hypofractionated WBRT after breast-conserving therapy for early-stage breast cancer. SEARCH METHODS On 27 August 2020, we searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and three trial databases. We searched for grey literature: OpenGrey (September 2020), reference lists of articles, conference proceedings and published abstracts, and applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible. DATA COLLECTION AND ANALYSIS Two review authors (BH and ML) performed data extraction, used Cochrane's risk of bias tool and resolved any disagreements through discussion, and assessed the certainty of the evidence for main outcomes using GRADE. Main outcomes were local recurrence-free survival, cosmesis, overall survival, toxicity (subcutaneous fibrosis), cause-specific survival, distant metastasis-free survival and subsequent mastectomy. We entered data into Review Manager 5 for analysis. MAIN RESULTS We included nine RCTs that enrolled 15,187 women who had invasive breast cancer or ductal carcinoma in-situ (6.3%) with T1-2N0-1M0 Grade I or II unifocal tumours (less than 2 cm or 3 cm or less) treated with breast-conserving therapy with negative margins. This is the second update of the review and includes two new studies and 4432 more participants. Local recurrence-free survival is probably slightly reduced (by 3/1000, 95% CI 6 fewer to 0 fewer) with the use of PBI/APBI compared to WBRT (hazard ratio (HR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 8 studies, 13,168 participants; moderate-certainty evidence). Cosmesis (physician/nurse-reported) is probably worse (by 63/1000, 95% CI 35 more to 92 more) with the use of PBI/APBI (odds ratio (OR) 1.57, 95% CI 1.31 to 1.87; 6 studies, 3652 participants; moderate-certainty evidence). Overall survival is similar (0/1000 fewer, 95% CI 6 fewer to 6 more) with PBI/APBI and WBRT (HR 0.99, 95% CI 0.88 to 1.12; 8 studies, 13,175 participants; high-certainty evidence). Late radiation toxicity (subcutaneous fibrosis) is probably increased (by 14/1000 more, 95% CI 102 more to 188 more) with PBI/APBI (OR 5.07, 95% CI 3.81 to 6.74; 2 studies, 3011 participants; moderate-certainty evidence). The use of PBI/APBI probably makes little difference (1/1000 less, 95% CI 6 fewer to 3 more) to cause-specific survival (HR 1.06, 95% CI 0.83 to 1.36; 7 studies, 9865 participants; moderate-certainty evidence). We found the use of PBI/APBI compared with WBRT probably makes little or no difference (1/1000 fewer (95% CI 4 fewer to 6 more)) to distant metastasis-free survival (HR 0.95, 95% CI 0.80 to 1.13; 7 studies, 11,033 participants; moderate-certainty evidence). We found the use of PBI/APBI in comparison with WBRT makes little or no difference (2/1000 fewer, 95% CI 20 fewer to 20 more) to mastectomy rates (OR 0.98, 95% CI 0.78 to 1.23; 3 studies, 3740 participants, high-certainty evidence). AUTHORS' CONCLUSIONS It appeared that local recurrence-free survival is probably worse with PBI/APBI; however, the difference was small and nearly all women remain free of local recurrence. Overall survival is similar with PBI/APBI and WBRT, and we found little to no difference in other oncological outcomes. Some late effects (subcutaneous fibrosis) may be worse with PBI/APBI and its use is probably associated with worse cosmetic outcomes. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver PBI/APBI. We await completion of ongoing trials.
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Affiliation(s)
- Brigid E Hickey
- Radiation Oncology Raymond Terrace, Princess Alexandra Hospital, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Margot Lehman
- School of Medicine, The University of Queensland, Brisbane, Australia
- Division of Cancer Services, Princess Alexandra Hospital, Brisbane, Australia
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13
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Haussmann J, Budach W, Strnad V, Corradini S, Krug D, Schmidt L, Tamaskovics B, Bölke E, Simiantonakis I, Kammers K, Matuschek C. Comparing Local and Systemic Control between Partial- and Whole-Breast Radiotherapy in Low-Risk Breast Cancer-A Meta-Analysis of Randomized Trials. Cancers (Basel) 2021; 13:2967. [PMID: 34199281 PMCID: PMC8231985 DOI: 10.3390/cancers13122967] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE/OBJECTIVE The standard treatment for localized low-risk breast cancer is breast-conserving surgery, followed by adjuvant radiotherapy and appropriate systemic therapy. As the majority of local recurrences occur at the site of the primary tumor, numerous trials have investigated partial-breast irradiation (PBI) instead of whole-breast treatment (WBI) using a multitude of irradiation techniques and fractionation regimens. This meta-analysis addresses the impact on disease-specific endpoints, such as local and regional control, as well as disease-free survival of PBI compared to that of WBI in published randomized trials. MATERIAL AND METHODS We conducted a systematic literature review and searched for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was based on the published event rates and the effect sizes for available oncological endpoints of at least two trials reporting on them. We evaluated in-breast tumor recurrences (IBTR), local recurrences at the primary site and elsewhere in the ipsilateral breast, regional recurrences (RR), distant metastasis-free interval (DMFI), disease-free survival (DFS), contralateral breast cancer (CBC), and second primary cancer (SPC). Furthermore, we aimed to assess the impact of different PBI techniques and subgroups on IBTR. We performed all statistical analyses using the inverse variance heterogeneity model to pool effect sizes. RESULTS For the intended meta-analysis, we identified 13 trials (overall 15,561 patients) randomizing between PBI and WBI. IBTR was significantly higher after PBI (OR = 1.66; CI-95%: 1.07-2.58; p = 0.024) with an absolute difference of 1.35%. We detected significant heterogeneity in the analysis of the PBI technique with intraoperative radiotherapy resulting in higher local relapse rates (OR = 3.67; CI-95%: 2.28-5.90; p < 0.001). Other PBI techniques did not show differences to WBI in IBTR. Both strategies were equally effective at the primary tumor site, but PBI resulted in statistically more IBTRs elsewhere in the ipsilateral breast. IBTRs after WBI were more likely to be located at the primary tumor bed, whereas they appeared equally distributed within the breast after PBI. RR was also more frequent after PBI (OR = 1.75; CI-95%: 1.07-2.88; p < 0.001), yet we did not detect any differences in DMFI (OR = 1.08; CI-95%: 0.89-1.30; p = 0.475). DFS was significantly longer in patients treated with WBI (OR = 1.14; CI-95%: 1.02-1.27; p = 0.003). CBC and SPC were not different in the test groups (OR = 0.81; CI-95%: 0.65-1.01; p = 0.067 and OR = 1.09; CI-95%: 0.85-1.40; p = 0.481, respectively). CONCLUSION Limiting the target volume to partial-breast radiotherapy appears to be appropriate when selecting patients with a low risk for local and regional recurrences and using a suitable technique.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Vratislav Strnad
- Department of Radiation Oncology, University Erlangen, 91054 Erlangen, Germany;
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU (Ludwig Maximillian), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Livia Schmidt
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Ioannis Simiantonakis
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
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14
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Meduri B, De Rose F, Cabula C, Castellano I, Da Ros L, Grassi MM, Orrù S, Puglisi F, Trimboli RM, Ciabattoni A. Hypofractionated breast irradiation: a multidisciplinary review of the Senonetwork study group. Med Oncol 2021; 38:67. [PMID: 33970358 DOI: 10.1007/s12032-021-01514-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/23/2021] [Indexed: 11/30/2022]
Abstract
The multidisciplinary management represents a crucial part of the care for cancer patients, resulting in better clinical and process outcomes, with evidence of improved survival among different cancer primary sites, including breast. According with international recommendations established by the European Society of Breast Cancer Specialists (EUSOMA), all breast-cancer patients have to be evaluated by a multidisciplinary team including radiologist, pathologist, surgeon, medical oncologist and radiation oncologist. Thus, variations in clinical practice of each specialty should be discussed and shared with all team members to guarantee a fruitful cooperation among the involved specialists. During the last decades, radiation treatment was deeply changed by the evidence-based adoption of hypofractionated radiotherapy (HFRT) as standard of treatment in patients with early-stage breast cancer undergoing conservative surgery. Moreover, mature randomized data have showed that partial breast irradiation (PBI) is an effective and safe alternative to whole breast irradiation in selected patients with low-risk early-stage breast cancer. Based on this background, we reviewed indications and critical issues of HFRT and PBI analyzing impact of their adoption from a multidisciplinary perspective.
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Affiliation(s)
- Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy
| | - Fiorenza De Rose
- Radiation Oncology Unit, Santa Chiara Hospital, Largo Medaglie d'oro 9, 38123, Trento, Italy.
| | - Carlo Cabula
- Oncologic Surgery, A. Businco Oncologic Hospital, Cagliari, Italy
| | - Isabella Castellano
- Pathology Unit, Department of Medical Sciences, "City of Health and Science University Hospital", University of Turin, Turin, Italy
| | - Lucia Da Ros
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | | | - Sandra Orrù
- Pathology Unit, P.O. Businco, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Fabio Puglisi
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Rubina Manuela Trimboli
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30 San Donato Milanese, 20097, Milan, Italy
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15
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Rahimi A, Morgan HE, Kim DW, Zhang Y, Leitch M, Wooldridge R, Goudreau S, Haley B, Rao R, Rivers A, Spangler AE, Jones RT, Stevenson S, Staley J, Albuquerque K, Ahn C, Neufeld S, Alluri PG, Ding C, Garwood D, Seiler S, Zhao B, Gu X, Timmerman R. Cosmetic Outcomes of a Phase 1 Dose Escalation Study of 5-Fraction Stereotactic Partial Breast Irradiation for Early Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2021; 110:772-782. [PMID: 33476737 DOI: 10.1016/j.ijrobp.2021.01.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Our purpose was to evaluate cosmetic changes after 5-fraction adjuvant stereotactic partial breast irradiation (S-PBI). METHODS AND MATERIALS Seventy-five women with in situ or invasive breast cancer stage 0, I, or II, with tumor size ≤3 cm, were enrolled after lumpectomy in a phase 1 dose escalation trial of S-PBI into cohorts receiving 30, 32.5, 35, 37.5, or 40 Gy in 5 fractions. Before S-PBI, 3 to 4 gold fiducial markers were placed in the lumpectomy cavity for tracking with the Synchrony respiratory tracking system. S-PBI was delivered with a CyberKnife robotic radiosurgery system. Patients and physicians evaluated global cosmesis using the Harvard Breast Cosmesis Scale. Eight independent panelists evaluated digital photography for global cosmesis and 10 subdomains at baseline and follow-up. McNemar tests were used to evaluate change in cosmesis, graded as excellent/good or fair/poor, from baseline to year 3. Wilcoxon signed rank tests were used to evaluate change in subdomains. Cohen's kappa (κ) statistic was used to estimate interobserver agreement (IOA) between raters, and Fleiss' κ was used to estimate IOA between panelists. RESULTS Median cosmetic follow-up was 5, 5, 5, 4, and 3 years for the 30, 32.5, 35, 37.5, and 40 Gy cohorts. Most patients reported excellent/good cosmesis at both baseline (86.3%) and year 3 (89.8%). No dose cohort had significantly worsened cosmesis by year 3 on McNemar analysis. No cosmetic subdomain had significant worsening by year 3. IOA was fair for patient-physician (κ = 0.300, P < .001), patient-panel (κ = 0.295, P < .001), physician-panel (κ = 0.256, P < .001), and individual panelists (Fleiss κ = 0.327, P < .001). CONCLUSIONS Dose escalation of S-PBI from 30 to 40 Gy in 5 fractions for early stage breast cancer was not associated with a detectable change in cosmesis by year 3. S-PBI is a promising modality for treatment of early stage breast cancer.
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Affiliation(s)
- Asal Rahimi
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Howard E Morgan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dong W Kim
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yuanyuan Zhang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Marilyn Leitch
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rachel Wooldridge
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sally Goudreau
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Barbara Haley
- Department of Medicine, Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Roshni Rao
- Department of Surgery, Columbia University, New York, New York
| | - Aeisha Rivers
- Department of Surgery, Memorial Health Care System, Pembroke Pines, Florida
| | - Ann E Spangler
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ryan T Jones
- Department of Radiation Oncology, Tennessee Oncology, Nashville, Tennessee
| | - Stella Stevenson
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jason Staley
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chul Ahn
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sarah Neufeld
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Prasanna G Alluri
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chuxiong Ding
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dan Garwood
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephen Seiler
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bo Zhao
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, Uniondale, New York
| | - Xuejun Gu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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16
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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: 36] [Impact Index Per Article: 9.0] [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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17
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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: 1.0] [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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18
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Goldberg M, Whelan TJ. Accelerated Partial Breast Irradiation (APBI): Where Are We Now? CURRENT BREAST CANCER REPORTS 2020; 12:275-284. [PMID: 33101597 PMCID: PMC7568840 DOI: 10.1007/s12609-020-00384-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2020] [Indexed: 01/26/2023]
Abstract
Purpose of Review Accelerated partial breast irradiation (APBI) is an alternative approach to breast conserving therapy (BCT) where radiation (RT) is delivered over a shorter period of time compared with whole breast irradiation (WBI), resulting in improved patient convenience and cost savings. APBI can be delivered using brachytherapy, intraoperative RT, or conformal external beam radiation therapy (EBRT) techniques. In this review, the authors appraise the latest modern randomized controlled trials (RCTs) of APBI and discuss the application of the data to clinical practice. Recent Findings The OCOG-RAPID and NSABP B-39/RTOG 0413 trials recently reported long-term outcomes of APBI. The OCOG-RAPID trial delivered 38.5 Gy/10 fractions twice daily (at least 6 h apart using EBRT) or WBI and demonstrated non-inferiority of APBI compared with WBI (8-year cumulative rate of ipsilateral breast tumor recurrence (IBTR) was 3% after APBI or 2.8% after WBI, HR 1.27, 90%CI: 0.84–1.91). While acute toxicity was reduced, late toxicity and breast cosmesis were worse with APBI. The NSABP B-39 trial included higher risk patients and was unable to demonstrate equivalence between APBI (38.5 Gy/10 fractions delivered twice daily using EBRT or brachytherapy techniques) and WBI. However, 10-year IBTR rates were low: 4.6% vs. 3.9%, respectively, HR 1.22, 90%CI: 0.94–1.58. The University of Florence demonstrated low rates of local recurrence at 10 years and overall excellent breast cosmetic outcomes when APBI was delivered using EBRT to a dose of 30 Gy/5 fractions delivered on non-consecutive days. Summary Recent RCTs of APBI have shed light on important factors for the integration of APBI into clinical practice, including patient selection and treatment delivery. APBI should be limited to patients with low-risk ductal carcinoma in situ or early stage (T1) invasive ductal cancer with clear margins of excision, estrogen receptor positivity, and node negative disease. Ongoing research should focus on the optimal dose/fractionation for delivery of EBRT-based APBI.
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Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
| | - Timothy J. Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
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Yee C, Lam E, Gallant F, Karam I, Czarnota G, Soliman H, Wong G, Drost L, Vesprini D, Rakovitch E, Wronski M, Leung E, Szumacher E, Carothers K, Pon K, Gonzales G, Easton L, Lewis D, Zhang L, Chow E. A Feasibility Study of Mepitel Film for the Prevention of Breast Radiation Dermatitis in a Canadian Center. Pract Radiat Oncol 2020; 11:e36-e45. [PMID: 32949772 DOI: 10.1016/j.prro.2020.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/23/2020] [Accepted: 09/08/2020] [Indexed: 11/15/2022]
Abstract
PURPOSE Severe radiation dermatitis (RD) is distressing and may have adverse long-term effects including fibrosis and telangiectasia. Treatment interruptions due to severe RD may increase the risk of recurrence. Two randomized trials of Mepitel film demonstrated efficacy in preventing severe RD in breast cancer, but this product has not been widely adopted in North America. We aimed to assess the feasibility and efficacy of Mepitel film for prevention of breast RD at a Canadian center. METHODS AND MATERIALS Patients were stratified based on breast size and receipt of postmastectomy radiation therapy. The primary outcome was RD grade using the Common Terminology Criteria for Adverse Events. Secondary outcomes included moist desquamation, patient- and clinician-reported symptoms of skin toxicity, and cosmetic outcomes. RESULTS Thirty patients receiving external beam radiation therapy to the breast or chest wall were enrolled. Two patients (6.7%) discontinued use of the Mepitel film before completing radiation therapy. No patients developed grade 3 RD or higher. Five patients (17.9%) developed grade 2 RD: 3 (10.7%) had moist desquamation, and 2 (7.1%) had brisk erythema without moist desquamation. CONCLUSIONS Mepitel film completely prevented grade 3 RD. Rates of moist desquamation and grade 2 RD were lower with Mepitel film than in studies using aqueous cream, but unlike previous trials of Mepitel film we did not achieve complete prevention of moist desquamation. Further research is needed to confirm the efficacy of Mepitel film versus standard prophylaxis for RD and identify the patients who will benefit the most from the film.
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Affiliation(s)
- Caitlin Yee
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Emily Lam
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Francois Gallant
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Irene Karam
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Gregory Czarnota
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Hany Soliman
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Gina Wong
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Leah Drost
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Danny Vesprini
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Eileen Rakovitch
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Matt Wronski
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Eric Leung
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Ewa Szumacher
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Kathy Carothers
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Kucy Pon
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Glen Gonzales
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Linda Easton
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Donna Lewis
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Liying Zhang
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Edward Chow
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
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20
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Pérez-Echagüen S, Sanz-Freire CJ, Guinot-Rodríguez JL, Gutiérrez-Miguélez C, Samper-Ots P, González-Pérez V, Villafranca-Iturre E, Modolell I, Pellejero-Pellejero S, Cambeiro-Vázquez M, Ossola-Lentati G. Consensus statement from the Spanish Brachytherapy Group (GEB) on accelerated partial breast irradiation using multicatheter interstitial brachytherapy. Rep Pract Oncol Radiother 2020; 25:832-839. [DOI: 10.1016/j.rpor.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/16/2020] [Accepted: 05/13/2020] [Indexed: 11/16/2022] Open
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21
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No Difference in Overall Survival and Non-Breast Cancer Deaths after Partial Breast Radiotherapy Compared to Whole Breast Radiotherapy-A Meta-Analysis of Randomized Trials. Cancers (Basel) 2020; 12:cancers12082309. [PMID: 32824414 PMCID: PMC7464494 DOI: 10.3390/cancers12082309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 01/20/2023] Open
Abstract
Purpose/objective: Adjuvant radiotherapy after breast conserving surgery is the standard approach in early stage breast cancer. However, the extent of breast tissue that has to be targeted with radiation has not been determined yet. Traditionally, the whole breast was covered by two opposing tangential beams. Several randomized trials have tested partial breast irradiation (PBI) compared to whole breast irradiation (WBI) using different radiation techniques. There is evidence from randomized trials that PBI might result in lower mortality rates compared to WBI. We aimed to reassess this question using current data from randomized trials. 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 overall survival (OS), breast cancer-specific survival (BCSS), and non-breast cancer death (NBCD) as investigated endpoints. Analysis of subgroups using different radiation techniques was intended. We used hazard ratios (HR) and risk differences (RD) to estimate pooled effect sizes. Statistical analysis was performed using the inverse variance heterogeneity model. Results: We identified eleven studies randomizing between PBI and WBI. We did not find significant differences in OS (n = 14,070; HR = 1.02; CI-95%: 0.89–1.16; p = 0.810, and n = 15,203; RD = −0.001; CI-95%: −0.008–0.006; p = 0.785) and BCSS (n = 15,203; RD = 0.001; CI-95%: −0.002–0.005; p = 0.463). PBI also did not result in a significant decrease of NBCD (n = 15,203; RD = −0.003; CI-95%: −0.010–0.003; p = 0.349). A subgroup analysis by radiation technique also did not point to any detectable differences. Conclusion: In contrast to a previous assessment of mortality, we could not find a detrimental effect of WBI on OS or NBCD. A longer follow-up might be necessary to fully assess the long-term mortality effects of PBI compared to WBI.
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22
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Hepel JT, Wazer DE. Partial Breast Irradiation Is the Preferred Standard of Care for a Majority of Women With Early‐Stage Breast Cancer. J Clin Oncol 2020; 38:2268-2272. [DOI: 10.1200/jco.19.02594] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Jaroslaw T. Hepel
- Department of Radiation Oncology, Lifespan Cancer Institute, Alpert Medical School, Brown University, Providence, RI
| | - David E. Wazer
- Department of Radiation Oncology, Lifespan Cancer Institute, Alpert Medical School, Brown University, Providence, RI
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23
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Recht A. Whole-Breast Irradiation Is the Preferred Standard of Care for the Majority of Patients With Early-Stage Breast Cancer. J Clin Oncol 2020; 38:2263-2267. [PMID: 32442072 DOI: 10.1200/jco.19.02388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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24
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Quirk S, Grendarova P, Craighead P, Phan T, Lesiuk M, Pinilla J, Liu HW, Wilson J, Bignell K, Austin T, Olivotto IA, Roumeliotis M. Results of the ACCEL trial: Dosimetry in accelerated partial breast irradiation. Radiother Oncol 2020; 147:50-55. [DOI: 10.1016/j.radonc.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/17/2020] [Accepted: 03/03/2020] [Indexed: 12/25/2022]
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25
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Mészáros N, Smanykó V, Major T, Stelczer G, Jánváry L, Kovács E, Mária B, Zaka Z, Pukancsik D, Takácsi-Nagy Z, Polgár C. Implementation of Stereotactic Accelerated Partial Breast Irradiation Using Cyber-Knife - Technical Considerations and Early Experiences of a Phase II Clinical Study. Pathol Oncol Res 2020; 26:2307-2313. [PMID: 32472440 PMCID: PMC7471183 DOI: 10.1007/s12253-020-00821-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 05/12/2020] [Indexed: 12/25/2022]
Abstract
To report the implementation, dosimetric results of and early experiences with stereotactic accelerated partial breast irradiation (SAPBI) following breast conserving surgery (BCS) for postmenopausal low-risk St I-II invasive breast cancer (IBC) patients. Between November 2018 and August 2019, 27 patients were registered in our phase II prospective study. SAPBI was performed with Cyber-Knife (CK) M6 machine, in 4 daily fractions of 6.25 Gy to a total dose of 25 Gy. Respiratory movements were followed with implanted gold markers and Synchrony system. Corrections for patient displacement and respiratory movement during treatment were performed with the robotic arm. Early side effects, cosmetic results, and dosimetric parameters were assessed. The average volume of the surgical cavity, clinical target volume (CTV), and planning target volume (PTV_EVAL) were 8.1 cm3 (range: 1.75–27.3 cm3), 55.3 cm3 (range: 26.2–103.5 cm3), and 75.7 cm3 (range: 40–135.4 cm3), respectively. The mean value of the PTV_eval/whole breast volume ratio was 0.09 (range: 0.04–0.19). No grade 2 or worst acute side-effect was detected. Grade 1 (G1) erythema occurred in 6 (22.2%) patients, while G1 oedema was reported by 3 (11.1%) cases. G1 pain was observed in 1 (3.4%) patient. Cosmetic result were excellent in 17 (62.9%) and good in 10 (37.1%) patients. SAPBI with CK is a suitable and practicable technique for the delivery of APBI after BCS for low-risk, St. I-II. IBC. Our early findings are encouraging, CK-SAPBI performed with four daily fractions is convenient and perfectly tolerated by the patients.
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Affiliation(s)
- Norbert Mészáros
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary. .,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary.
| | - Viktor Smanykó
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary.,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Gábor Stelczer
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Levente Jánváry
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Eszter Kovács
- Department of Radiology, National Institute of Oncology, Budapest, Hungary
| | - Bahéri Mária
- Department of Radiology, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Zaka
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Dávid Pukancsik
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary.,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary.,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
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26
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Lim-Reinders S, Keller BM, Sahgal A, Chugh B, Kim A. Measurement of surface dose in an MR-Linac with optically stimulated luminescence dosimeters for IMRT beam geometries. Med Phys 2020; 47:3133-3142. [PMID: 32302010 DOI: 10.1002/mp.14185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 12/31/2022] Open
Abstract
PURPOSE This study aims to measure the surface dose on an anthropomorphic phantom for intensity-modulated radiation therapy (IMRT) plans treated in a 1.5 T magnetic resonance (MR)-Linac. Previous studies have used Monte Carlo programs to simulate surface dose and have recognized high surface dose as a potential limiting factor for the MR-Linac; however, to our knowledge surface dose measurement for clinical plans has not yet been published. Given the novelty of the MR-Linac, it is important to perform in vivo measurements of a potentially dose-limiting factor such as surface dose when moving forward for clinical use. METHODS Optically stimulated luminescence dosimeters (OSLDs) were used on an anthropomorphic phantom. Intensity-modulated radiation therapy plans were generated to treat a near-surface breast tumor in the phantom. The tumor was treated with 2, 3, 5, 7, and 9 beam IMRT plans with a 1.5 T MR-Linac using a 7-MV photon beam. The plans were generated in a Monte Carlo treatment planning system (TPS) capable of modeling magnetic field effects. The surface dose was sampled in seven locations on the surface surrounding the planning target volume (PTV), and in two different OSLD configurations with the dosimeters measuring water equivalent depths of 0.16 and 0.64 mm. The TPS was used to estimate the doses at the OSLD locations. In addition, MR images were taken of a pork belly with and without an OSLD placed anteriorly placed to determine the effect of an OSLD on image fidelity. RESULTS For the 3, 5, 7, and 9-beam configurations, surface doses were approximately half that of the prescription dose to the simulated tumor, although the magnitude of the skin dose relative to the prescription is certainly also dependent on individual patient anatomy. The general trend for both TPS and measurements was that the greater the number of beams, the lower the skin doses and dose readings; also, with increasing numbers of beams, doses at shallow depths become lower relative to deeper depths. The MR images showed that the presence of the OSLD did not induce clinically relevant geometric distortions or intensity differences. CONCLUSIONS To our knowledge, this study is the first of its kind to experimentally measure the surface dose in an MR-Linac for IMRT plans. This study has explored the use of OSLDs to measure in vivo surface dose in a clinical setting. OSLDs may be used to measure skin dose clinically when there are concerns of skin radiation burns and near-surface toxicity. Optically stimulated luminescence dosimeters are promising devices for in vivo surface dosimetry in an MR-Linac.
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Affiliation(s)
- Stephanie Lim-Reinders
- Sunnybrook Health Sciences Centre/Odette Cancer Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.,Faculty of Medicine, Medical Sciences Building, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Brian M Keller
- Faculty of Medicine, Medical Sciences Building, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.,Department of Radiation Oncology, Faculty of Medicine, University of Toronto, 149 College Street, Suite 504, Toronto, ON, M5T 1P5, Canada
| | - Arjun Sahgal
- Faculty of Medicine, Medical Sciences Building, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.,Department of Radiation Oncology, Faculty of Medicine, University of Toronto, 149 College Street, Suite 504, Toronto, ON, M5T 1P5, Canada
| | - Brige Chugh
- Faculty of Medicine, Medical Sciences Building, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.,Department of Radiation Oncology, Faculty of Medicine, University of Toronto, 149 College Street, Suite 504, Toronto, ON, M5T 1P5, Canada
| | - Anthony Kim
- Faculty of Medicine, Medical Sciences Building, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.,Department of Radiation Oncology, Faculty of Medicine, University of Toronto, 149 College Street, Suite 504, Toronto, ON, M5T 1P5, Canada
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27
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White J, Thompson A, Whelan T. Accelerated Partial Breast Irradiation and Intraoperative Partial Breast Irradiation: Reducing the Burden of Effective Breast Conservation. J Clin Oncol 2020; 38:2254-2262. [PMID: 32442062 DOI: 10.1200/jco.20.00070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Julia White
- Department of Radiation Oncology, The James, Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Alastair Thompson
- Section of Breast Surgery, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX
| | - Timothy Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, Ontario, Canada
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28
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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: 0.3] [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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29
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Souchon R. [Reducing the risk of ipsilateral breast tumor relapse: external beam accelerated partial breast irradiation vs. whole breast irradiation following breast-conserving surgery in patients with ductal carcinoma in situ and node-negative breast cancer : The multicentric randomised RAPID trial]. Strahlenther Onkol 2020; 196:579-582. [PMID: 32342118 DOI: 10.1007/s00066-020-01609-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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30
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Forster T, Köhler CVK, Debus J, Hörner-Rieber J. Accelerated Partial Breast Irradiation: A New Standard of Care? Breast Care (Basel) 2020; 15:136-147. [PMID: 32398982 DOI: 10.1159/000506254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 01/29/2020] [Indexed: 01/19/2023] Open
Abstract
Background Breast-conserving therapy including lumpectomy and adjuvant whole breast irradiation (WBI) has become the standard therapy for early-stage breast cancer (EBC). Without WBI, the recurrence rate is significantly increased. However, when selecting patients at a low a priori risk of local recurrence only a small breast-cancer-specific mortality benefit, but no overall survival improvement, was detected for WBI. As most recurrences occur close to the lumpectomy cavity, accelerated partial breast irradiation (APBI) delivered exclusively to a limited volume of tissue around the initial lumpectomy site, has gained increased attention and is now discussed as an alternative to WBI for selected EBC patients. Summary Numerous techniques for APBI (interstitial brachytherapy, external beam-based APBI, intraoperative radiotherapy, MR-guided radiotherapy) allow treatment delivery in a shorter period of time, and radiation oncologists expect to further reduce side effects by using these new techniques, with improvements in cosmetics and quality of life. In this review, we aim to describe the existing evidence for the feasibility and effectiveness of different APBI techniques used in modern radiotherapy. Key Messages APBI has provided outcomes similar to WBI combined with potentially reduced toxicity. While appropriate patient selection persists to be crucial for acceptable recurrence rates, the precise definition of patients suitable for APBI remains a matter of discussion. As long-term data are often still lacking, special attention should be paid to late side effects and long-term outcomes. Decision-making on appropriate treatment techniques should take into account not only local control rates, but also the impact on the patient's quality of life.
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Affiliation(s)
- Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | | | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,German Cancer Consortium (DKTK), partner site Heidelberg, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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Volume de-escalation in radiation therapy: state of the art and new perspectives. J Cancer Res Clin Oncol 2020; 146:909-924. [PMID: 32072318 DOI: 10.1007/s00432-020-03152-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/10/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE New RT techniques and data emerging from follow-up for several tumor sites suggest that treatment volume de-escalation may permit to minimize therapy-related side effects and/or obtain better clinical outcomes. Here, we summarize the main evidence about volume de-escalation in RT. METHOD The relevant literature from PubMed was reviewed in this article. The ClinicalTrials.gov database was searched for clinical trials related to the specific topic. RESULTS In Lymphoma, large-volume techniques (extended- and involved-field RT) are being successfully replaced by involved-site RT and involved-node RT. In head and neck carcinoma, spare a part of elective neck is controversial. In early breast cancer, partial breast irradiation has been established as a treatment option in low-risk patients. In pancreatic cancer stereotactic body radiotherapy may be used to dose escalation. Stereotactic radiosurgery should be the treatment choice for patients with oligometastatic brain disease and a life expectancy of more than 3 months, and it should be considered an alternative to WBRT for patients with multiple brain metastases. CONCLUSION Further clinical trials are necessary to improve the identification of suitable patient cohorts and the extent of possible volume de-escalation that does not compromise tumor control.
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Impact of Regional Nodal Irradiation and Hypofractionated Whole-Breast Radiation on Long-Term Breast Retraction and Poor Cosmetic Outcome in Breast Cancer Survivors. Clin Breast Cancer 2020; 20:e75-e81. [DOI: 10.1016/j.clbc.2019.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/12/2019] [Accepted: 08/23/2019] [Indexed: 11/22/2022]
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Bosma SCJ, Leij F, Vreeswijk S, Maaker MD, Wesseling J, Vijver MVD, Scholten A, Rivera S, Bourgier C, Auzac G, Foukakis T, Lekberg T, Bongard D, Loo C, Rutgers E, Bartelink H, Elkhuizen PHM. Five-Year Results of the Preoperative Accelerated Partial Breast Irradiation (PAPBI) Trial. Int J Radiat Oncol Biol Phys 2020; 106:958-967. [PMID: 31987957 DOI: 10.1016/j.ijrobp.2019.12.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE In this multicenter phase 2 feasibility study, we investigated the impact of preoperative accelerated partial breast irradiation (PAPBI) on local control, breast fibrosis, and cosmetic outcome. METHODS AND MATERIALS Women aged >60 years with an invasive, unifocal (mammography and magnetic resonance imaging), nonlobular adenocarcinoma of the breast were treated with PAPBI. Six weeks after radiation therapy, a wide local excision was performed. Radiation therapy consisted of 10 × 4 Gy (2010-2013) or 5 × 6 Gy (after 2013) to the tumor (gross target volume) with a 25 mm margin (20 mm from gross target volume to clinical target volume, 5 mm planning target volume). RESULTS One hundred thirty-three patients treated between 2010 and 2016 were analyzed with a median follow-up of 5.0 years (0.9-8.8 years). Seventy-eight (59%) patients were treated with 10 × 4 Gy in 2 weeks and 55 (41%) patients with 5 × 6 Gy in 1 week. Eighteen postoperative complications (14%) occurred in 15 patients (11%). The proportion of patients with no to mild fibrosis in the treated part of the breast at 2 years and later time points was around 90%. Cosmesis improved over time in several patients: excellent to good cosmetic score as rated by the physician was 68% at 6 months and 92% at 5 years. Seventy-seven percent (6 months) to 82% (5 years) of patients were "satisfied" or "very satisfied" with their cosmetic outcome. Three recurrences were detected in the biopsy track and 1 recurrence in the ipsilateral breast. CONCLUSIONS PAPBI is a feasible method with a low postoperative complication rate, limited fibrosis, and good to excellent cosmetic outcome. The local recurrence rate was 3% at 5 years; however, no local recurrences were observed since removal of the needle biopsy track.
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Affiliation(s)
- Sophie C J Bosma
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Femke Leij
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sandra Vreeswijk
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel de Maaker
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Astrid Scholten
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Celine Bourgier
- Department of Radiation Oncology, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | - Guillaume Auzac
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Theodoros Foukakis
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Lekberg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Desiree Bongard
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Claudette Loo
- Department of Radiology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Emiel Rutgers
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Harry Bartelink
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Whelan TJ, Julian JA, Berrang TS, Kim DH, Germain I, Nichol AM, Akra M, Lavertu S, Germain F, Fyles A, Trotter T, Perera FE, Balkwill S, Chafe S, McGowan T, Muanza T, Beckham WA, Chua BH, Gu CS, Levine MN, Olivotto IA. External beam accelerated partial breast irradiation versus whole breast irradiation after breast conserving surgery in women with ductal carcinoma in situ and node-negative breast cancer (RAPID): a randomised controlled trial. Lancet 2019; 394:2165-2172. [PMID: 31813635 DOI: 10.1016/s0140-6736(19)32515-2] [Citation(s) in RCA: 253] [Impact Index Per Article: 50.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whole breast irradiation delivered once per day over 3-5 weeks after breast conserving surgery reduces local recurrence with good cosmetic results. Accelerated partial breast irradiation (APBI) delivered over 1 week to the tumour bed was developed to provide a more convenient treatment. In this trial, we investigated if external beam APBI was non-inferior to whole breast irradiation. METHODS We did this multicentre, randomised, non-inferiority trial in 33 cancer centres in Canada, Australia and New Zealand. Women aged 40 years or older with ductal carcinoma in situ or node-negative breast cancer treated by breast conserving surgery were randomly assigned (1:1) to receive either external beam APBI (38·5 Gy in ten fractions delivered twice per day over 5-8 days) or whole breast irradiation (42·5 Gy in 16 fractions once per day over 21 days, or 50 Gy in 25 fractions once per day over 35 days). Patients and clinicans were not masked to treatment assignment. The primary outcome was ipsilateral breast tumour recurrence (IBTR), analysed by intention to treat. The trial was designed on the basis of an expected 5 year IBTR rate of 1·5% in the whole breast irradiation group with 85% power to exclude a 1·5% increase in the APBI group; non-inferiority was shown if the upper limit of the two-sided 90% CI for the IBTR hazard ratio (HR) was less than 2·02. This trial is registered with ClinicalTrials.gov, NCT00282035. FINDINGS Between Feb 7, 2006, and July 15, 2011, we enrolled 2135 women. 1070 were randomly assigned to receive APBI and 1065 were assigned to receive whole breast irradiation. Six patients in the APBI group withdrew before treatment, four more did not receive radiotherapy, and 16 patients received whole breast irradiation. In the whole breast irradiation group, 16 patients withdrew, and two more did not receive radiotherapy. In the APBI group, a further 14 patients were lost to follow-up and nine patients withdrew during the follow-up period. In the whole breast irradiation group, 20 patients were lost to follow-up and 35 withdrew during follow-up. Median follow-up was 8·6 years (IQR 7·3-9·9). The 8-year cumulative rates of IBTR were 3·0% (95% CI 1·9-4·0) in the APBI group and 2·8% (1·8-3·9) in the whole breast irradiation group. The HR for APBI versus whole breast radiation was 1·27 (90% CI 0·84-1·91). Acute radiation toxicity (grade ≥2, within 3 months of radiotherapy start) occurred less frequently in patients treated with APBI (300 [28%] of 1070 patients) than whole breast irradiation (484 [45%] of 1065 patients, p<0·0001). Late radiation toxicity (grade ≥2, later than 3 months) was more common in patients treated with APBI (346 [32%] of 1070 patients) than whole breast irradiation (142 [13%] of 1065 patients; p<0·0001). Adverse cosmesis (defined as fair or poor) was more common in patients treated with APBI than in those treated by whole breast irradiation at 3 years (absolute difference, 11·3%, 95% CI 7·5-15·0), 5 years (16·5%, 12·5-20·4), and 7 years (17·7%, 12·9-22·3). INTERPRETATION External beam APBI was non-inferior to whole breast irradiation in preventing IBTR. Although less acute toxicity was observed, the regimen used was associated with an increase in moderate late toxicity and adverse cosmesis, which might be related to the twice per day treatment. Other approaches, such as treatment once per day, might not adversely affect cosmesis and should be studied. FUNDING Canadian Institutes for Health Research and Canadian Breast Cancer Research Alliance.
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Affiliation(s)
- Timothy J Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada.
| | - Jim A Julian
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Tanya S Berrang
- Radiation Therapy Program, BC Cancer - Victoria, University of British Columbia, Vancouver, BC, Canada
| | - Do-Hoon Kim
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Isabelle Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada
| | - Alan M Nichol
- Division of Radiation Oncology, University of British Columbia and BC Cancer - Vancouver, BC, Canada
| | - Mohamed Akra
- Department of Radiation Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Sophie Lavertu
- Department of Radiation Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Francois Germain
- Department of Radiation Oncology, CHU de Québec - Université Laval, Québec, QC, Canada; Division of Radiation Oncology, University of British Columbia and BC Cancer - Kelowna, BC, Canada
| | - Anthony Fyles
- Department of Radiation Oncology, University of Toronto and Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Francisco E Perera
- Department of Oncology, Western University and London Regional Cancer Program, London, ON, Canada
| | | | - Susan Chafe
- Department of Oncology, Division of Radiation Oncology, University of Alberta and Cross Cancer Institute, Edmonton, AB, Canada
| | - Thomas McGowan
- Trillium Health Partners Credit Valley Hospital, Mississauga, ON, Canada
| | - Thierry Muanza
- Department of Oncology, McGill University and Jewish General Hospital Segal Cancer Centre, Montreal, QC, Canada
| | - Wayne A Beckham
- Department of Physics and Astronomy, University of Victoria and BC Cancer - Victoria, BC, Canada
| | - Boon H Chua
- University of New South Wales and Prince of Wales Hospital, Sydney, NSW, Australia
| | - Chu Shu Gu
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Mark N Levine
- Department of Oncology, McMaster University and Juravinski Cancer Centre, Hamilton, ON, Canada
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Grendarova P, Roumeliotis M, Quirk S, Lesiuk M, Craighead P, Liu HW, Pinilla J, Wilson J, Bignell K, Phan T, Olivotto IA. One-Year Cosmesis and Fibrosis From ACCEL: Accelerated Partial Breast Irradiation (APBI) Using 27 Gy in 5 Daily Fractions. Pract Radiat Oncol 2019; 9:e457-e464. [DOI: 10.1016/j.prro.2019.04.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/28/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022]
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Bhattacharya IS, Haviland JS, Perotti C, Eaton D, Gulliford S, Harris E, Coles CE, Kirwan CC, Bliss JM, Kirby AM. Is breast seroma after tumour resection associated with patient-reported breast appearance change following radiotherapy? Results from the IMPORT HIGH (CRUK/06/003) trial. Radiother Oncol 2019; 136:190-196. [PMID: 31015124 PMCID: PMC6598856 DOI: 10.1016/j.radonc.2019.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/15/2019] [Accepted: 03/24/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Seroma describes a collection of serous fluid within a cavity, occurring following surgery. Seroma is associated with normal tissue effects (NTE) following breast radiotherapy, as reported by clinicians and on photographs. This study investigates the association between seroma and the NTE breast appearance change collected using patient-reported outcome measures (PROMs) in IMPORT HIGH, as well as investigating the association between breast appearance change and patient/tumour/treatment factors. METHODS Case-control methodology was used for seroma analysis within IMPORT HIGH. Cases were patients reporting moderate/marked breast appearance change and controls reported none/mild changes at year-3. One control was selected at random for each case. Seromas were graded as not visible/subtle or visible/highly visible on CT radiotherapy planning scans. Logistic regression tested associations, adjusting for patient/tumour/treatment factors. RESULTS 1078/1149 patients consented to PROMs, of whom 836 (78%) reported whether they had 3-year breast appearance change; 231 cases and 231 controls were identified. 304/462 (66%) patients received chemotherapy. Seroma prevalence was 20% (41/202) in cases and 16% (32/205) in controls, and less frequent in patients receiving adjuvant chemotherapy [10% (24/246) compared with 29% (40/138) without]. Visible seroma was not significantly associated with breast appearance change [OR 1.38 (95%CI 0.83-2.29), p = 0.219]. Larger tumour size, haematoma, current smoking and body image concerns at baseline were independent risk factors. CONCLUSIONS Seroma was not associated with patient-reported breast appearance change, but haematoma and smoking were significant risk factors. Lack of association may be related to lower prevalence of seroma compared with previous reports, perhaps reflecting patients receiving adjuvant chemotherapy in whom seroma resolves prior to radiotherapy.
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Affiliation(s)
- Indrani S Bhattacharya
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), United Kingdom.
| | - Joanne S Haviland
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), United Kingdom.
| | | | - David Eaton
- Mount Vernon Hospital, National Radiotherapy Trials QA Group, United Kingdom.
| | - Sarah Gulliford
- The Institute of Cancer Research, Radiotherapy and Imaging, United Kingdom; University College London Hospital, London, UK.
| | - Emma Harris
- The Institute of Cancer Research, Radiotherapy and Imaging, United Kingdom.
| | | | - Cliona C Kirwan
- Institute of Cancer Sciences, University of Manchester, University Hospital of South Manchester, United Kingdom.
| | - Judith M Bliss
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), United Kingdom.
| | - Anna M Kirby
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Radiotherapy and Imaging, United Kingdom.
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Catheter-based delineation of lumpectomy cavity for accurate target definition in partial-breast irradiation with multicatheter interstitial brachytherapy. J Contemp Brachytherapy 2019; 11:108-115. [PMID: 31139218 PMCID: PMC6536147 DOI: 10.5114/jcb.2019.84504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 03/03/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose In partial-breast irradiation (PBI), accurate lumpectomy cavity (LC) delineation is critical. Seroma-based delineation (SBD) using computed tomography (CT) with clips remains uncertain, causing an expansion of the LC and planning target volume (PTV). In catheter-based delineation (CBD), the implanted catheters were used as reference markers for LC delineation in multicatheter interstitial brachytherapy (MIB). Material and methods Between October 2008 and October 2018, 513 patients who underwent MIB-PBI were examined. In CBD, anatomical relations of LC to catheters were recorded. In randomly selected 22 CBD cases, the LC volume and PTV were retrospectively recontoured on SBD, and the relationship between the contribution of CBD and cavity visuality was evaluated. The LC volume and PTV before and after the introduction of CBD were compared. Results The mean LC volumes based on SBD and CBD were 19.1 cm3 and 14.1 cm3, respectively (p < 0.001). The mean PTVs based on SBD and CBD were 47.9 cm3 and 35.7 cm3, respectively (p < 0.0001). More reductions in the LC volume (5.1 cm3) (p < 0.05) and PTV (7.7 cm3) (p = 0.13) were observed in the poorly visible LC than in the visible LC. The LC volume and PTV before the introduction of CBD (n = 411) were compared with those after introduction (n = 102). Significant reductions were observed in the LC volume (5.9 cm3) (p < 0.0001) after the introduction of CBD; moreover, PTV tended to be reduced (3.9 cm3) (p = 0.17). Conclusions CBD may help to establish the standardized procedure for MIB-PBI and prevent unnecessary radiation exposure to the normal breast tissue.
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Korzets Y, Fyles A, Shepshelovich D, Amir E, Goldvaser H. Toxicity and clinical outcomes of partial breast irradiation compared to whole breast irradiation for early-stage breast cancer: a systematic review and meta-analysis. Breast Cancer Res Treat 2019; 175:531-545. [DOI: 10.1007/s10549-019-05209-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/18/2019] [Indexed: 11/25/2022]
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Abstract
In New Zealand, oncoplastic surgery is common, but partial breast reconstruction presents challenges for radiation therapy targeting. Tissue rearrangement creates ambiguity when targeting the tumor bed, with resultant overestimation of treatment volumes. Thus, adoption of advanced methods of radiation therapy have been hindered. This pilot study describes use of a novel three-dimensional implant that provides a scaffolding for tissue ingrowth during partial breast reconstruction and delineates the tumor bed more precisely to assist radiation planning and mammographic surveillance. After informed consent, 15 women were implanted with the three-dimensional bioabsorbable implant. The device was sutured to the tumor bed during lumpectomy, and tissue flaps were mobilized and attached to the implant. Visualization of the marker and radiation treatment volumes were recorded and compared. The implant provided volume replacement and helped to maintain breast contour. Cosmetic outcomes were excellent; no device- or radiation-related complications occurred. One patient had a postoperative hematoma that resolved after percutaneous drainage; there were no postoperative infections. Three-year follow-up shows no tumor recurrences and no untoward effects. When compared to conventional radiation targeting, use of the implant showed that a greater than 50 percent reduction in treatment volume was possible in some cases. Three-year mammograms show no significant artifact, normal tissue ingrowth, and minimal fibrosis. This study describes a method of oncoplastic breast reconstruction using an implantable device that marks the site of tumor excision and provides for volume replacement with tissue ingrowth. Patients tolerated it well, and radiation therapy planning, positioning, and treatment were facilitated.
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Gaudet M, Pharand-Charbonneau M, Wright D, Nguyen J, Trudel-Sabourin J, Chelfi M. Long-term results of multicatheter interstitial high-dose-rate brachytherapy for accelerated partial-breast irradiation. Brachytherapy 2018; 18:211-216. [PMID: 30554991 DOI: 10.1016/j.brachy.2018.11.004] [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: 09/28/2018] [Revised: 11/03/2018] [Accepted: 11/12/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to report the long-term results of women treated in one center with accelerated partial-breast irradiation (APBI) with interstitial high-dose-rate (HDR) brachytherapy. MATERIALS AND METHODS We analyzed data from women treated in one center with adjuvant interstitial HDR brachytherapy for early-stage breast cancer. Treatment regimen was homogeneous for all women with treatment dose 32Gy in 8 fractions twice daily given to the tumor bed with interstitial HDR brachytherapy. RESULTS About 364 women were treated with interstitial HDR brachytherapy as APBI from March 2000 to March 2014. Mean age at diagnosis was 62 years. Stage distribution was as follows: T1a = 12%, T1b = 33%, T1c = 40%, T2 = 14%, and Tis = 1%. 97% of patients were N0. 88% had invasive ductal carcinoma. 86% had positive hormone receptor status. 14 ipsilateral breast tumor recurrences were identified with 12 deemed local recurrences and 2 deemed to be second ipsilateral primaries. Actuarial 5-year and 10-year overall survival rates were 95.1% and 92.2%, respectively. Actuarial 5-year and 10-year local relapse-free survival rates were 96.2% and 88.8%, respectively. CONCLUSIONS The results of this previously unreported series of women treated with a homogeneous APBI method exclusively with interstitial HDR brachytherapy present further data justifying that in appropriately selected women, APBI with interstitial brachytherapy provides rates of local control and survival comparable with whole-breast irradiation.
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Affiliation(s)
- Marc Gaudet
- Département de radio-oncologie, Centre Intégré de Santé et de Services Sociaux de l'Outaouais, Gatineau, Quebec, Canada; Division of Radiation Oncology, The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Mathieu Pharand-Charbonneau
- Département de radio-oncologie, Centre Intégré de Santé et de Services Sociaux de l'Outaouais, Gatineau, Quebec, Canada
| | - Debbie Wright
- Département de radio-oncologie, Centre Intégré de Santé et de Services Sociaux de l'Outaouais, Gatineau, Quebec, Canada
| | - Jonathan Nguyen
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | | | - Mustapha Chelfi
- Département de radio-oncologie, Centre Intégré de Santé et de Services Sociaux de l'Outaouais, Gatineau, Quebec, Canada
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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: 2.5] [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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Predictors for poor cosmetic outcome in patients with early stage breast cancer treated with breast conserving therapy: Results of the Young boost trial. Radiother Oncol 2018; 128:434-441. [DOI: 10.1016/j.radonc.2018.06.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/27/2018] [Accepted: 06/12/2018] [Indexed: 11/21/2022]
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Stecklein SR, Shaitelman SF, Babiera GV, Bedrosian I, Black DM, Ballo MT, Arzu I, Strom EA, Reed VK, Dvorak T, Smith BD, Woodward WA, Hoffman KE, Schlembach PJ, Kirsner SM, Nelson CL, Yang J, Guerra W, Dibaj S, Bloom ES. Prospective Comparison of Toxicity and Cosmetic Outcome After Accelerated Partial Breast Irradiation With Conformal External Beam Radiotherapy or Single-Entry Multilumen Intracavitary Brachytherapy. Pract Radiat Oncol 2018; 9:e4-e13. [PMID: 30125673 DOI: 10.1016/j.prro.2018.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/26/2018] [Accepted: 08/07/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aimed to prospectively characterize toxicity and cosmesis after accelerated partial breast irradiation (APBI) with 3-dimensional conformal radiation therapy (CRT) or single-entry, multilumen, intracavitary brachytherapy. METHODS AND MATERIALS A total of 281 patients with pTis, pT1N0, or pT2N0 (≤3.0 cm) breast cancer treated with segmental mastectomy were prospectively enrolled from December 2008 through August 2014. APBI was delivered using 3-dimensional CRT (n = 29) or with SAVI (n = 176), Contura (n = 56), or MammoSite (n = 20) brachytherapy catheters. Patients were evaluated at protocol-specified intervals, at which time the radiation oncologist scored cosmetic outcome, toxicities, and recurrence status using a standardized template. RESULTS The median follow-up time is 41 months. Grade 1 seroma and fibrosis were more common with brachytherapy than with 3-dimensional CRT (50.4% vs 3.4% for seroma; P < .0001 and 66.3% vs 44.8% for fibrosis; P = .02), but grade 1 edema was more common with 3-dimensional CRT than with brachytherapy (17.2% vs 5.6%; P = .04). Grade 2 to 3 pain was more common with 3-dimensional CRT (17.2% vs 5.2%; P = .03). Actuarial 5-year rates of fair or poor radiation oncologist-reported cosmetic outcome were 9% for 3-dimensional CRT and 24% for brachytherapy (P = .13). Brachytherapy was significantly associated with inferior cosmesis on mixed model analysis (P = .003). Significant predictors of reduced risk of adverse cosmetic outcome after brachytherapy were D0.1cc (skin) ≤102%, minimum skin distance >5.1 mm, dose homogeneity index >0.54, and volume of nonconformance ≤0.89 cc. The 5-year ipsilateral breast recurrence was 4.3% for brachytherapy and 4.2% for 3-dimensional CRT APBI patients (P = .95). CONCLUSIONS Brachytherapy APBI is associated with higher rates of grade 1 fibrosis and seroma than 3-dimensional CRT but lower rates of grade 1 edema and grade 2 to 3 pain than 3-dimensional CRT. Rates of radiation oncologist-reported fair or poor cosmetic outcomes are higher with brachytherapy. We identified dosimetric parameters that predict reduced risk of adverse cosmetic outcome after brachytherapy-based APBI. Ipsilateral breast recurrence was equivalent for brachytherapy and 3-dimensional CRT.
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Affiliation(s)
- Shane R Stecklein
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Gildy V Babiera
- Department of Breast Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Dalliah M Black
- Department of Breast Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Matthew T Ballo
- Department of Radiation Oncology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Isadora Arzu
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Eric A Strom
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Valerie K Reed
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Tomas Dvorak
- Department of Radiation Oncology, UFHealth Cancer Center/Orlando Health, Orlando, Florida
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Wendy A Woodward
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Pamela J Schlembach
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Steve M Kirsner
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Christopher L Nelson
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - William Guerra
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Shiva Dibaj
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth S Bloom
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas.
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Five-field IMRT class solutions and dosimetric planning guidelines for implementing accelerated partial breast irradiation. Pract Radiat Oncol 2018; 8:e99-e107. [DOI: 10.1016/j.prro.2017.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 08/29/2017] [Accepted: 09/20/2017] [Indexed: 12/25/2022]
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Franco P, Iorio GC, Bartoncini S, Airoldi M, De Sanctis C, Castellano I, Ricardi U. De-escalation of breast radiotherapy after conserving surgery in low-risk early breast cancer patients. Med Oncol 2018; 35:62. [PMID: 29616366 DOI: 10.1007/s12032-018-1121-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 03/30/2018] [Indexed: 12/12/2022]
Abstract
The reduction in the burden related to treatment is becoming more and more important in modern oncology. Radiation therapy is a mainstay option in the postoperative setting for early breast cancer patients after breast-conserving surgery. Nowadays, different options are available to de-escalate radiotherapy in this scenario such as the use of hypofractionated whole-breast radiation, the selective delivery of the boost dose to the lumpectomy cavity, the introduction of accelerated partial breast irradiation and the omission of treatment in appropriately selected patients with low-risk features. We herein provide a review article on this topic.
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Affiliation(s)
- Pierfrancesco Franco
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy.
| | - Giuseppe Carlo Iorio
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Sara Bartoncini
- Department of Oncology, Radiation Oncology, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Mario Airoldi
- Department of Medical Sciences, Pathology Unit, University of Turin, Turin, Italy
| | - Corrado De Sanctis
- Department of Gynecology and Obstetrics, Breast Unit, AOU Città della Salute e della Scienza, Turin, Italy
| | - Isabella Castellano
- Department of Oncology, Medical Oncology 2, AOU Città della Salute e della Scienza, Turin, Italy
| | - Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
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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: 10] [Impact Index Per Article: 1.4] [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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47
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Kim A, Lim-Reinders S, McCann C, Ahmad SB, Sahgal A, Lee J, Keller BM. Magnetic field dose effects on different radiation beam geometries for hypofractionated partial breast irradiation. J Appl Clin Med Phys 2017; 18:62-70. [PMID: 28901729 PMCID: PMC5689934 DOI: 10.1002/acm2.12182] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Hypofractionated partial breast irradiation (HPBI) involves treatment to the breast tumor using high doses per fraction. Recent advances in MRI-Linac solutions have potential in being applied to HPBI due to gains in the soft tissue contrast of MRI; however, there are potentially deleterious effects of the magnetic field on the dose distribution. The purpose of this work is to determine the effects of the magnetic field on the dose distribution for HPBI tumors using a tangential beam arrangement (TAN), 5-beam intensity-modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT). METHODS Five patients who have received HPBI were selected with two patients having bilateral disease resulting in a total of two tumors in this study. Six planning configurations were created using a treatment planning system capable of modeling magnetic field dose effects: TAN, IMRT and VMAT beam geometries, each of these optimized with and without a transverse magnetic field of 1.5 T. RESULTS The heart and lung doses were not statistically significant when comparing plan configurations. The magnetic field had a demonstrated effect on skin dose: for VMAT plans, the skin (defined to a depth of 3 mm) D1cc was elevated by +11% and the V30 by +146%; for IMRT plans, the skin D1cc was increased by +18% and the V30 by +149%. Increasing the number of beam angles (e.g., going from IMRT to VMAT) with the magnetic field on reduced the skin dose. CONCLUSION The impact of a magnetic field on HPBI dose distributions was analyzed. The heart and lung doses had clinically negligible effects caused by the magnetic field. The magnetic field increases the skin dose; however, this can be mitigated by increasing the number of beam angles.
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Affiliation(s)
- Anthony Kim
- Department of Medical Physics, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, ON, Canada.,Faculty of Medicine, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Stephanie Lim-Reinders
- Department of Medical Physics, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, ON, Canada
| | - Claire McCann
- Department of Medical Physics, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, ON, Canada.,Faculty of Medicine, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Syed Bilal Ahmad
- Department of Medical Physics, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, ON, Canada
| | - Arjun Sahgal
- Faculty of Medicine, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, ON, Canada
| | - Justin Lee
- Faculty of Medicine, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Department of Radiation Oncology, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, ON, Canada
| | - Brian M Keller
- Department of Medical Physics, Sunnybrook Health Sciences Centre/Odette Cancer Centre, Toronto, ON, Canada.,Faculty of Medicine, Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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Charaghvandi RK, Yoo S, van Asselen B, Rodrigues A, van den Bongard DHJG, Horton JK. Treatment constraints for single dose external beam preoperative partial breast irradiation in early-stage breast cancer. Clin Transl Radiat Oncol 2017; 6:7-14. [PMID: 29594217 PMCID: PMC5862640 DOI: 10.1016/j.ctro.2017.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 06/14/2017] [Indexed: 12/25/2022] Open
Abstract
Background Following breast-conserving surgery and post-operative 3D-conformal accelerated partial breast irradiation (APBI), suboptimal cosmetic results have been reported. Preoperative radiation delivery to the intact tumor enables better target visualization and treatment volume reduction. Single dose preoperative APBI has the potential to improve toxicity profiles, reduce treatment burden and enable in vivo exploration of breast cancer radiogenomics. Purpose Develop practical guidelines for single dose external beam preoperative APBI. Methods Recommended dose constraints were derived from pooled dosimetry estimates from 2 clinical trials. In an American dose escalation trial, a uniform 15, 18 or 21 Gy dose has previously been evaluated for non-lobular cT1N0 or low/intermediate grade DCIS <2 cm in prone position (n = 32). In the Netherlands, the feasibility of ablative APBI (20 Gy to GTV, 15 Gy to CTV) to non-lobular cT1N0 in supine position, is currently being explored (n = 15). The dosimetric adherence to the developed constraints was evaluated in new APBI plans with a 21 Gy uniform dose but an extended CTV margin (n = 32). Results Dosimetric data pooling enabled the development of practical guidelines for single dose preoperative APBI. Conclusion The developed guidelines will allow further explorations in the promising field of single dose preoperative external beam APBI for breast cancer treatment.
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Affiliation(s)
- Ramona K Charaghvandi
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sua Yoo
- Department of Radiation Oncology, Duke Cancer Center, Durham, USA
| | - Bram van Asselen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anna Rodrigues
- Department of Radiation Oncology, Duke Cancer Center, Durham, USA
| | | | - Janet K Horton
- Department of Radiation Oncology, Duke Cancer Center, Durham, USA
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Lightowlers SV, Boersma LJ, Fourquet A, Kirova YM, Offersen BV, Poortmans P, Scholten AN, Somaiah N, Coles CE. Preoperative breast radiation therapy: Indications and perspectives. Eur J Cancer 2017; 82:184-192. [PMID: 28692950 DOI: 10.1016/j.ejca.2017.06.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 05/25/2017] [Accepted: 06/11/2017] [Indexed: 10/19/2022]
Abstract
Preoperative breast radiation therapy (RT) is not a new concept, but older studies failed to change practice. More recently, there has been interest in revisiting preoperative RT using modern techniques. This current perspective discusses the indications, summarises the published literature and then highlights current clinical trials, with particular attention to combining with novel drugs and optimising associated translational research.
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Affiliation(s)
- S V Lightowlers
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, United Kingdom.
| | - L J Boersma
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - A Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Y M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - B V Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - P Poortmans
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - A N Scholten
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - N Somaiah
- The Institute of Cancer Research, London, United Kingdom
| | - C E Coles
- Oncology Centre, University of Cambridge, United Kingdom
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50
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Dragun AE, Ajkay NJ, Riley EC, Roberts TL, Pan J, Rai SN, Jain D, Quillo AR, Scoggins CR, McMasters KM, Woo SY. First Results of a Phase 2 Trial of Once-Weekly Hypofractionated Breast Irradiation (WHBI) for Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2017; 98:595-602. [DOI: 10.1016/j.ijrobp.2017.01.212] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 01/16/2017] [Accepted: 01/19/2017] [Indexed: 11/17/2022]
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