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Kil WJ, Smith W, Herndon C, Shipe W. Continuous Positive Airway Pressure-Assisted Breathing With Supine Tangential Left Breast Radiation Therapy When Deep Inspiration Breath-Hold Radiation Therapy Was Ineffective or Unsuitable: Clinical Implications for an Affordable Heart-Sparing Breast Radiation Therapy to Reduce the Health Care Disparities in Low-Resource Settings. Adv Radiat Oncol 2024; 9:101472. [PMID: 38681888 PMCID: PMC11043812 DOI: 10.1016/j.adro.2024.101472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/04/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose To report continuous positive airway pressure (CPAP)-assisted breathing with supine tangential left breast radiation therapy (CPAP-RT) when deep inspiration breath-hold RT (DIBH-RT) was ineffective or unsuitable. Methods and Materials Ten patients with left breast cancer underwent computed tomography simulation scan (CT-sim) under DIBH followed by CPAP-assisted breathing (15 cm H2O) to create CPAP-RT plans in authors' institute. Reasons for CPAP-RT include inability to reproduce DIBH (n = 5), DIBH-RT plan exceeded dose limits to the heart (n = 2), and unable to proceed with planned DIBH-RT due to mechanical issues (n = 3). Radiation target volumes and organs at risk were contoured according to published atlas data. For dosimetric comparison, supine tangential fields for breast only RT (Breast-RT) and wide-tangential fields for breast + internal mammary nodal RT (Breast + IMN-RT) were used with prescription of 40 Gy in 15 fractions on each patients' CT-sim with free-breathing (FB), DIBH, and CPAP-assisted breathing, respectively. Results Planning target volume (PTV) coverage was acceptable and comparable in all RT plans. Compared with FB, both DIBH and CPAP-assisted breathing inflated the thorax and increased left lung volume on average by 46% and 51%, respectively (FB: 1230 vs DIBH: 1802 vs CPAP-assisted breathing:1860 cc, P < .01), and increased the shortest distance between PTVeval-Breast to the heart by 5.6 ± 3.0 and 11.9 ± 3.6 mm (P < .01) and to LAD by 4.9 ± 2.9 and 10.8 ± 4.3 mm, respectively (P < .01). Compared with FB, both DIBH and CPAP significantly reduced radiation dose to the heart and LAD. A mean dose to the heart (HeartDmean) was FB: 2.3 ± 0.9, DIBH: 1.2 ± 0.7, and CPAP: 0.9 ± 0.4 Gy in Breast-RT (P < .01); FB: 3.2 ± 1.7, DIBH: 1.7 ± 0.8, and CPAP: 1.3 ± 0.5 Gy in Breast + IMN-RT (P < .01). LADDmean was FB: 11 ± 4.5, DIBH: 5.4 ± 3.2, and CPAP: 2.4 ± 0.9 Gy in Breast-RT (P < .01); FB: 15.5 ± 7.8, DIBH: 7.4 ± 4.1, and CPAP: 3.5 ± 1.4 Gy in Breast + IMN-RT (P < .01). A maximum dose to LAD (LADDmax) was FB: 35.8 ± 8.7, DIBH: 22.4 ± 15.4, and CPAP: 7.8 ± 5.3 Gy in Breast-RT (P < .01); FB: 38.7 ± 5.0, DIBH: 25.3 ± 15.2, and CPAP: 10.2 ± 6.8 Gy in Breast + IMN-RT (P < .01). All patients successfully completed CPAP-RT. Conclusions CPAP-RT provides efficient and practical heart and LAD sparing RT using simple supine tangential fields for Breast-RT or wide-tangential fields for Breast + IMN-RT when DIBH-RT was ineffective or unsuitable. With its easy accessibility and low infrastructural requirement, CPAP-RT can provide affordable heart-sparing left breast RT to reduce the health care disparities in low-resource settings.
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Affiliation(s)
- Whoon Jong Kil
- Radiation Oncology, UPMC Hillman Cancer Center, Williamsport, Pennsylvania
- Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Wyatt Smith
- Radiation Oncology, UPMC Hillman Cancer Center, Williamsport, Pennsylvania
| | - Craig Herndon
- Radiation Oncology, UPMC Hillman Cancer Center, Williamsport, Pennsylvania
| | - Warren Shipe
- Radiation Oncology, UPMC Hillman Cancer Center, Williamsport, Pennsylvania
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Chirilă ME, Kraja F, Marta GN, Neves Junior WFP, de Arruda GV, Gouveia AG, Franco P, Poortmans P, Ratosa I. Organ-sparing techniques and dose-volume constrains used in breast cancer radiation therapy - Results from European and Latin American surveys. Clin Transl Radiat Oncol 2024; 46:100752. [PMID: 38425691 PMCID: PMC10900109 DOI: 10.1016/j.ctro.2024.100752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/12/2024] [Accepted: 02/17/2024] [Indexed: 03/02/2024] Open
Abstract
Background Advances in local and systemic therapies have improved the outcomes of patients with breast cancer (BC), leading to a possible increased risk for postoperative radiation therapy (RT) late adverse events. The most adequate technologies and dose constraints for organs at risk (OAR) in BC RT have yet to be defined. Methods An online survey was distributed to radiation oncologists (ROs) practicing in Europe and Latin America including the Caribbean (LAC) through personal contacts, RO and BC professional groups' networks. Demographic data and clinical practice information were collected. Results The study included 585 responses from ROs practicing in 57 different countries. The most frequently contoured OAR by European and LAC participants were the whole heart (96.6 % and 97.7 %), the ipsilateral (84.3 % and 90.8 %), and contralateral lung (71.3 % and 77.4 %), whole lung (69.8 % and 72.9 %), and the contralateral breast (66.4 % and. 83.2 %). ESTRO guidelines were preferred in Europe (33.3 %) and the RTOG contouring guideline was the most popular in LAC (62.2 %), while some participants used both recommendations (13.2 % and 19.2 %). IMRT (68.6 % and 59.1 %) and VMAT (65.6 % and 60.2 %) were the preferred modalities used in heart sparing strategies, followed by deep inspiration breath-hold (DIBH) (54.8 % and 37.4 %) and partial breast irradiation (PBI) (41.6 % and 24.6 %). Only a small percentage of all ROs reported the dose-volume constraints for OAR used in routine clinical practice. A mean heart dose (Heart-Dmean) between 4 and 5 Gy was the most frequently reported parameter (17.2 % and 39.3 %). Conclusion The delineation approaches and sparing techniques for OAR in BC RT vary between ROs worldwide. The low response rate to the dose constraints subset of queries reflects the uncertainty surrounding this topic and supports the need for detailed consensus recommendations in the clinical practice.
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Affiliation(s)
- Monica-Emila Chirilă
- Radiation Oncology Department, Amethyst Radiotherapy Centre, Cluj-Napoca, Romania
- Department of Clinical Development, MVision AI, Helsinki, Finland
| | - Fatjona Kraja
- Surgery Department, Faculty of Medicine, University of Medicine Tirana, Albania
- Department of Oncology, University Hospital Centre Mother Teresa, Tirana, Albania
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sirio Libanês, São Paulo, Brazil
- Post-Graduation Program, Radiology and Oncology Department, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
| | - Wellington Furtado Pimenta Neves Junior
- Department of Radiation Oncology, Hospital Sirio Libanês, São Paulo, Brazil
- Post-Graduation Program, Radiology and Oncology Department, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Gustavo Viani de Arruda
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
- Department of Medical Imaging, Hematology and Oncology, Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - André Guimarães Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre, Brazil
- Department of Oncology, Division of Radiation Oncology, Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Pierfrancesco Franco
- Department of Translational Sciences (DIMET), University of Eastern Piedmont, Novara, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Faculty of Medicine and Health Sciences, University of Antwerp, Iridium Netwerk, Wilrijk-Antwerp, Belgium
| | - Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Slovenia
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Ratosa I, Montero A, Ciervide R, Alvarez B, García-Aranda M, Valero J, Chen-Zhao X, Lopez M, Zucca D, Hernando O, Sánchez E, de la Casa MA, Alonso R, Fernandez-Leton P, Rubio C. Ultra-hypofractionated one-week locoregional radiotherapy for patients with early breast cancer: Acute toxicity results. Clin Transl Radiat Oncol 2024; 46:100764. [PMID: 38516338 PMCID: PMC10955656 DOI: 10.1016/j.ctro.2024.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/26/2024] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Purpose Moderate hypofractionated radiotherapy is the standard of care for all patients with breast cancer, irrespective of stage or prior treatments. While extreme hypofractionation is accepted for early-stage tumours, its application in irradiating locoregional lymph nodes remains controversial. Materials and methods A prospective registry analysis from July 2020 to September 2023 included 276 patients with early-stage breast cancer treated with one-week ultra-hypofractionation (UHF) at 26 Gy in 5 fractions on the whole breast (58.3 %) or thoracic wall (41.7 %) and ipsilateral regional lymph nodes and simultaneous integrated boost (58.3 %). Primary endpoint was assessment of acute adverse events (AEs). Secondarily, onset of early-delayed toxicity was assessed. A minimum 6-month follow-up was required for assessing potential treatment-related early-delayed complications. Acute or late complications attributable to treatment were assessed at inclusion using the Common Terminology Criteria for Adverse Events (CTCAE) v5.0 criteria. Results With a median follow-up of 19 months (range 1-49 months), 159 (57.6 %) patients reported AEs, predominantly grade (G) 1 (n = 139, 50.4 %) and G2 (n = 20, 7.8 %). Skin acute toxicity was common (G1/2: 134, G3: 14), while breast oedema occurred in 10 patients (G1: 9, G2: 1), and 15.9 % reported breast pain (G1: 42, G2: 2). Ipsilateral arm oedema was observed in 1.8 % patients. For patients with a follow-up beyond 6 months (n = 213), 23.4 % patients reported G1/G2 skin AEs, 8.8 % had G1/G2 breast/chest wall oedema, and 8.9 % experienced arm lymphedema. There were no cases of brachial plexopathy or G3 toxicity in this group of patients. Conclusions One-week UHF adjuvant locoregional radiation is well-tolerated, displaying low-toxicity profiles comparable to other studies using similar irradiation schedules.
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Affiliation(s)
- Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Angel Montero
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Camilo José Cela, Madrid, Spain
| | - Raquel Ciervide
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Beatriz Alvarez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | | | - Xin Chen-Zhao
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Mercedes Lopez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Daniel Zucca
- Department of Medical Physics, HM Hospitales, Madrid, Spain
| | - Ovidio Hernando
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Emilio Sánchez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Rosa Alonso
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Carmen Rubio
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
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Prokofev I, Salim N. Off-isocentric VMAT technique for breast cancer: Effective dose reduction to organs at risk and its applicability based on patient anatomy. J Appl Clin Med Phys 2024; 25:e14237. [PMID: 38207110 DOI: 10.1002/acm2.14237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/10/2023] [Accepted: 11/27/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE This study aims to explore the off-isocentric volumetric modulated arc therapy (offVMAT) technique for breast cancer and determine its applicability based on patient anatomical parameters. METHODS We retrospectively analyzed 44 breast cancer patients with varied lymph node involvement using different arc designs. Off-isocentric techniques were benchmarked against previously published arc techniques: classic arcs (clVMAT), tangential arcs (tVMAT), and split arcs (spVMAT). During optimization, target coverage was made for all plans as close as possible to the criteria D99% > 95% and Dmax < 110% of the prescribed dose. A novel patient categorization, based on anatomical parameters (auxiliary structures) rather than lymph node involvement, is introduced. This categorization considers the volume of ipsilateral organs at risk (OARs) adjacent to the target. A binary regression model was developed on these anatomical parameters. It predicts the likelihood of offVMAT (P[offVMAT]) achieving better criteria. RESULTS Using the regression model, patients were divided into two groups: P(offVMAT) > 0.5 and P(offVMAT) < 0.5. For the P(offVMAT) > 0.5 group, most tVMAT plans are unable to achieve the clinical objectives. Comparing offVMAT with spVMAT, offVMAT exhibited better dose parameters for the heart (V20, V10, and D2 are 7.1, 2.4, and 1.5 times lower respectively), ipsilateral lung (V20, V10, V5 and the mean dose are 1.4, 1.3, 1.2, and 1.2 times lower respectively). The average doses to the contralateral side are consistent. In the P(offVMAT) < 0.5 group, the tVMAT technique showed increased doses at medium and high levels, yet reduced doses in contralateral OARs compared to spVMAT and offVMAT. spVMAT showed lower doses in the contralateral lung relative to the offVMAT technique, while clVMAT trailed in both groups. Validation of the model yielded a 90% accuracy rate. CONCLUSIONS The new off-isocentric breast planning technique effectively reduces doses to ipsilateral OARs, maintaining acceptable contralateral mean doses. This technique has an advantage over other techniques for patients with intricate anatomies. It is evaluated using anatomical parameters, which are also used to build binary regression model, which shows the dependence of anatomical parameters on whether offVMAT is preferred for individual patients. Also, such anatomical parameters provide a more objective and precise comparison between different planning techniques.
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Affiliation(s)
- Igor Prokofev
- Department of Radiotherapy, European Medical Center, Moscow, Russia
| | - Nidal Salim
- Department of Radiotherapy, European Medical Center, Moscow, Russia
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Zhang L, Mei X, Hu Z, Yu B, Zhang C, Li Y, Liu K, Ma X, Ma J, Chen X, Meng J, Shi W, Wang X, Mo M, Shao Z, Zhang Z, Yu X, Guo X, Yang Z. Adjuvant medial versus entire supraclavicular lymph node irradiation in high-risk early breast cancer (SUCLANODE): a protocol for a multicenter, randomized, open-label, phase 3 trial. BMC Cancer 2024; 24:49. [PMID: 38195438 PMCID: PMC10775440 DOI: 10.1186/s12885-024-11831-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 01/03/2024] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Supraclavicular nodal (SCL) irradiation is commonly used for patients with high-risk breast cancer after breast surgery. The Radiation Therapy Oncology Group (RTOG) and European Society for Radiotherapy and Oncology (ESTRO) breast contouring atlases delineate the medial part of the SCL region, while excluding the posterolateral part. However, recent studies have found that a substantial proportion of SCL failures are located in the posterolateral SCL region, outside of the RTOG/ESTRO-defined SCL target volumes. Consequently, many radiation oncologists advocate for enlarging the SCL irradiation target volume to include both the medial and posterolateral SCL regions. Nevertheless, it remains uncertain whether adding the posterolateral SCL irradiation improves survival outcomes for high-risk breast cancer patients. METHODS The SUCLANODE trial is an open-label, multicenter, randomized, phase 3 trial comparing the efficacy and adverse events of medial SCL irradiation (M-SCLI group) and medial plus posterolateral SCL irradiation (entire SCL irradiation, E-SCLI group) in high-risk breast cancer patients who underwent breast conserving-surgery or mastectomy. Patients with pathological N2-3b disease following initial surgery, or clinical stage III or pathological N1-3b if receiving neoadjuvant systemic therapy, are eligible and randomly assigned (1:1) to M-SCLI group and E-SCLI group. Stratification is by chemotherapy sequence (neoadjuvant vs. adjuvant), T stage (T3-4 vs. T1-2), N stage (N1-2 vs. N3), and ER status (positive vs. negative). Other radiation volumes are identical in the two arms, including breast/chest wall, undissected axillary lymph node, and internal mammary node. Advanced intensity modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT), or tomotherapy techniques are recommended. Both hypofractionated and conventional fractionation schedules are permitted. The primary end point is invasive disease-free survival, and secondary end points included overall survival, SCL recurrence, local-regional recurrence, distance recurrence, safety outcome, and patient-reported outcomes. The target sample size is 1650 participants. DISCUSSION The results of the SUCLANODE trial will provide high-level evidence regarding whether adding posterolateral SCL irradiation to medial SCL target volume provides survival benefit in patients with high-risk breast cancer. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05059379. Registered 28 September 2021, https://www. CLINICALTRIALS gov/ct2/show/NCT05059379 .
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Affiliation(s)
- Li Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xin Mei
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Zhigang Hu
- Department of Radiation Oncology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, 230001, China
| | - Bo Yu
- Department of Radiotherapy, the Affiliated Jiangyin Hospital of Nantong University, Jiangyin, 214400, China
| | - Chaoyang Zhang
- Department of Radiation Oncology, The First Hospital of Quanzhou Affiliated to Fujian Medical University, Fuzhou, China
| | - Yong Li
- Department of Oncology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Kaitai Liu
- Department of Radiation Oncology, The Affiliated Lihuili Hospital of Ningbo University, Ningbo, Zhejiang, 315040, China
| | - Xuejun Ma
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Jinli Ma
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xingxing Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Jin Meng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Wei Shi
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xiaofang Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Miao Mo
- Department of Cancer Prevention & Clinical Statistics Center, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Zhimin Shao
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
- Key Laboratory of Breast Cancer in Shanghai, Fudan University Shanghai Cancer Center, Shanghai, 200032, China
| | - Zhen Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xiaoli Yu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China
| | - Xiaomao Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China.
| | - Zhaozhi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 Dong-An Road, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
- Shanghai Key Laboratory of Radiation Oncology, Shanghai, 200032, China.
- Department of Medical Oncology, Kashgar Prefecture Second People ' s Hospital, Xinjiang Uyghur Autonomous Region, Kashgar, 844000, China.
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Naoum GE, Taghian AG. Regional Lymph Node Radiation Is Not the Main Risk Factor for Breast Cancer Related Lymphedema: Stop Chasing Radiation Doses, Fractionation or Techniques-Focus on Axillary Surgery De-escalation or Prevention. Int J Radiat Oncol Biol Phys 2023; 117:461-464. [PMID: 37652608 DOI: 10.1016/j.ijrobp.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 09/02/2023]
Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Northwestern University Memorial Hospital, Chicago, Illinois.
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Güzelöz Z, Ayrancıoğlu O, Aktürk N, Güneş M, Alıcıkuş ZA. Dose Volume and Liver Function Test Relationship following Radiotheraphy for Right Breast Cancer: A Multicenter Study. Curr Oncol 2023; 30:8763-8773. [PMID: 37887532 PMCID: PMC10605792 DOI: 10.3390/curroncol30100632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/19/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVE The liver is a critical organ at risk during right breast radiotherapy (RT). Liver function tests (LFTs) such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) serve as biochemical markers for hepatobiliary damage. In this multicenter cross-sectional study, the effects of liver dose-volume on changes in LFTs pre- and post-RT in patients treated for right breast cancer were evaluated. MATERIALS AND METHODS Between January 2019 and November 2022, data from 100 patients who underwent adjuvant right breast RT across three centers were retrospectively assessed. Target volumes and normal structures were contoured per the RTOG atlas. Patients were treated with a total dose of 50 Gy in 25 fractions to the CTV, followed by a boost to the tumor bed where indicated. The percentage change in LFT values in the first two weeks post-RT was calculated. Statistics were analyzed with SPSS version 22 software, with significance set at p < 0.05. Statistical correlation between liver doses (in cGy) and the volume receiving specific doses (Vx in cc) on the change in LFTs were analyzed using Kolmogorov-Smirnov, Mann-Whitney U test. RESULTS The median age among the 100 patients was 56 (range: 29-79). Breast-conserving surgery was performed on 75% of the patients. The most common T and N stages were T1 (53%) and N0 (53%), respectively. None of the patients had distant metastasis or simultaneous systemic treatment with RT. A total of 67% of the treatments utilized the IMRT technique and 33% VMAT. The median CTV volume was 802 cc (range: 214-2724 cc). A median boost dose of 10 Gy (range: 10-16 Gy) was applied to 28% of the patients with electrons and 51% with IMRT/VMAT. The median liver volume was 1423 cc (range: 825-2312 cc). Statistical analyses were conducted on a subset of 57 patients for whom all three LFT values were available both pre- and post-RT. In this group, the median values for AST, ALT, and GGT increased up to 15% post-RT compared to pre-RT, and a median liver Dmean below 208 cGy was found significant. While many factors can influence LFT values, during RT planning, attention to liver doses and subsequent regular LFT checks are crucial. CONCLUSION Due to factors such as anatomical positioning, planning technique, and breast posture, the liver can receive varying doses during right breast irradiation. Protecting patients from liver toxicity secondary to RT is valuable, especially in breast cancer patients with a long-life expectancy. Our study found that, even in the absence of any systemic treatment or risk factors, there was an average increase of nearly 15% in enzymes, indicating acute liver damage post-RT compared with pre-RT. Attention to liver doses during RT planning and regular follow-up with LFTs is essential.
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Affiliation(s)
- Zeliha Güzelöz
- Department of Radiation Oncology, Health Science University Tepecik Training and Research Hospital, İzmir 35100, Türkiye
| | - Oğuzhan Ayrancıoğlu
- Department of Radiation Oncology, İzmir Tınaztepe University Galen Hospital, İzmir 35001, Türkiye; (O.A.); (M.G.); (Z.A.A.)
| | - Nesrin Aktürk
- Department of Radiation Oncology, Katip Çelebi University Atatürk Training and Research Hospital, İzmir 35150, Türkiye;
| | - Merve Güneş
- Department of Radiation Oncology, İzmir Tınaztepe University Galen Hospital, İzmir 35001, Türkiye; (O.A.); (M.G.); (Z.A.A.)
| | - Zümre Arıcan Alıcıkuş
- Department of Radiation Oncology, İzmir Tınaztepe University Galen Hospital, İzmir 35001, Türkiye; (O.A.); (M.G.); (Z.A.A.)
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Wang DQ, Zhang N, Dong LH, Zhong YH, Wu HF, Zhong QZ, Jin J, Hou XR, Jing H, Tang Y, Hu C, Song YW, Liu YP, Qi SN, Tang Y, Lu NN, Chen B, Zhai YR, Zhang WW, Li N, Fang H, Li YX, Wang SL. Dose-Volume Predictors for Radiation Esophagitis in Patients With Breast Cancer Undergoing Hypofractionated Regional Nodal Radiation Therapy. Int J Radiat Oncol Biol Phys 2023; 117:186-197. [PMID: 37001764 DOI: 10.1016/j.ijrobp.2023.03.060] [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: 12/10/2022] [Revised: 03/17/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE Our objective was to assess the incidence and dose-volume predictors of radiation esophagitis (RE) in patients with breast cancer undergoing hypofractionated regional nodal irradiation. METHODS AND MATERIALS Eligible patients who received intensity modulated radiation therapy (RT) at the chest wall, the supraclavicular/infraclavicular fossa, level II axilla, and/or the internal mammary chain after mastectomy were included. The prescribed dose was 43.5 Gy in 15 fractions. RE was evaluated weekly during RT and at 1 and 2 weeks, followed by 3 and 6 months after RT, and was graded according to National Cancer Institute Common Toxicity Criteria for Adverse Events, version 3.0. The esophagus was contoured from the lower border level of the cricoid cartilage to the lower margin of the aortic arch. Esophageal total volume, mean dose, maximum dose, and the relative volumes (RV) and absolute volumes (AV) receiving at least 5 to 45 Gy by 5-Gy increments (RV5-RV45 and AV5-AV45) were evaluated. Univariable and multivariable logistic regression analyses were performed to determine risk factors for RE, and receiver operating characteristic curves were obtained to identify the thresholds of esophageal dosimetric parameters. RESULTS In total, 298 patients were included between May 8, 2020, and January 5, 2022 (minimum post-RT follow-up: 6 months). Grade 2 and 3 RE incidence was 40.9% (122/298) and 0.3% (1/298), respectively. No grade 4 or 5 RE was observed. Esophageal RV20-RV40 and AV35-AV40 were significantly associated with the risk of grade ≥2 RE after adjusting for tumor laterality and internal mammary nodal irradiation. RV25 and AV35 were optimum dose-volume predictors for grade ≥2 RE at thresholds 20% for RV25 (35.9% vs 60.9%; P = .04) and 0.27 mL for AV35 (31.0% vs 54.6%; P = .04). CONCLUSIONS RE is common in patients with breast cancer undergoing hypofractionated regional nodal irradiation. Maintaining the upper esophageal V25 at <20% and V35 at <0.27 mL may decrease the risk of RE.
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Affiliation(s)
- Dan-Qiong Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Na Zhang
- Department of Radiation Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Li-Hua Dong
- Department of Radiation Oncology, First Hospital, Jilin University, Changchun, China
| | - Ya-Hua Zhong
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Wuhan, China
| | - Hong-Fen Wu
- Department of Radiation Oncology, Cancer Hospital of Jilin Province, Changchun, China
| | - Qiu-Zi Zhong
- Department of Radiation Oncology, Beijing Hospital, Ministry of Health, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Xiao-Rong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Beijing, China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Rui Zhai
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-Wen Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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9
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Anjidani S, Siavashpour Z, Houshyari M, Haghgoo M, Nazarnejad M, Zayeri F, Alireza Javadinia S. A dosimetric comparative study following RTOG and ESTRO contouring guidelines for breast radiation therapy. Cancer Radiother 2023; 27:413-420. [PMID: 37482461 DOI: 10.1016/j.canrad.2023.06.003] [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: 05/24/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE To compare the dosimetric parameters considering the Radiation Therapy Oncology Group (RTOG) and European Society for Radiotherapy and Oncology (ESTRO) guidelines for breast cancer radiotherapy. Two radiotherapy techniques, intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT), were considered. PATIENTS AND METHODS Twenty-eight patients with left-sided medially-located TanyN2M0 tumors were contoured based on RTOG and ESTRO guidelines. 9-field IMRT, 10-field IMRT, 11-field IMRT, and VMAT treatment plans were applied as radiotherapy (RT) techniques for both contouring sets. The dosimetric parameters of the RT plans were extracted and compared. RESULTS Comparing dose-volume histogram (DVH) parameters, equivalent uniform dose (EUD), and normal tissue complication probability (NTCP) of OARs across the contouring guidelines and considering each RT technique showed that the only significant differences were higher Dmax, Dmean, V30, and V45, EUD, and NTCP of the thyroid in all treatment modalities when the RTOG guideline had been adopted. Using the VMAT technique, PTV's EUD and the tumor control probability (TCP) were considerably higher when the ESTRO guideline was adopted. Moreover, the conformity index (CI) of VMAT plans was significantly higher when the ESTRO guideline was used. CONCLUSION Unless having higher doses to thyroid when the RTOG guideline was adopted, the doses to other organs-at-risk (OAR) were similar between the two considering guidelines. Moreover, except for higher EUD, TCP, and CI for VMAT when the ESTRO guideline was used, no other significant differences were obtained between dosimetric parameters of target volumes considering the RT techniques and contouring guidelines.
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Affiliation(s)
- Sh Anjidani
- Radiotherapy Oncology Department, Shohada-e Tajrish Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Z Siavashpour
- Radiotherapy Oncology Department, Shohada-e Tajrish Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - M Houshyari
- Radiotherapy Oncology Department, Shohada-e Tajrish Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Haghgoo
- Department of Control Engineering, School of Electrical and Computer Engineering, Tarbiat Modares University (TMU), Tehran, Iran
| | - M Nazarnejad
- Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - F Zayeri
- Proteomics Research Center and Department of Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Qods Square, Darband Street, Tehran, Iran
| | - S Alireza Javadinia
- Non-Communicable Diseases Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran
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10
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Kaidar-Person O, Giasafaki P, Boersma L, De Brouwer P, Weltens C, Kirkove C, Peignaux-Casasnovas K, Budach V, van der Leij F, Vonk E, Weidner N, Rivera S, van Tienhoven G, Fourquet A, Noel G, Valli M, Guckenberger M, Koiter E, Racadot S, Abdah-Bortnyak R, Bartelink H, Struikmans H, Fortpied C, Poortmans PM. Mapping the location of local and regional recurrences according to breast cancer surgery and radiation therapy: Results from EORTC 22922/10925. Radiother Oncol 2023; 185:109698. [PMID: 37211281 DOI: 10.1016/j.radonc.2023.109698] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/23/2023]
Abstract
The purpose of this study is to evaluate the influence of the extent of surgery and radiation therapy (RT) on the rates and sites of local (LR) and regional recurrences (RR) in the EORTC 22922/10925 trial. PATIENTS AND METHODS All data were extracted from the trial's individual patients' case report forms (CRF) and analysed with a median follow-up of 15.7 years. Cumulative incidence curves were produced for LR and RR accounting for competing risks: an exploratory analysis of the effect of the extent of surgical and radiation treatments on LR rate was conducted using the Fine & Gray model accounting for competing risks and adjusted for baseline patient and disease characteristics. The significance level was set at 5%, 2-sided. Frequency tables were used to describe the spatial location of LR and RR. RESULTS Out of 4004 patients included in the trial, 282 (7%) patients experienced LR and 165 (4.1%) RR, respectively. Cumulative incidence rate of LR at 15 years was lower after mastectomy (3.1%) compared to BCS + RT (7.3%) (F&G: HR (Hazard Ratio) = 0.421, 95%CI = 0.282-0.628, p-value < 0.0001). LR were similar up to 3 years for both mastectomy and BCS but continued to occur at a steady rate for BCS + RT, only. The spatial location of the recurrence was related to the locoregional therapy applied and the absolute gain of RT correlated to stage of disease and extent of surgery. CONCLUSIONS The extent of locoregional therapies impacts significantly on LR and RR rates and spatial location.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Dept. Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | | | - Liesbeth Boersma
- Dept. Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Peter De Brouwer
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - Caroline Weltens
- Department of Radiation Oncology, University Hospital Leuven, KU Leuven faculty of medicine, Leuven, Belgium
| | - Carine Kirkove
- Department of Radiation Oncology, University Hospital Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | - Volker Budach
- Department of Radiation Oncology and Radiotherapy, Comprehensive Cancer Center, Charite University Medicine, Berlin, Germany
| | - Femke van der Leij
- Department of Radiation Oncology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Ernest Vonk
- Institute for Radiation Oncology RISO, Deventer, The Netherlands
| | - Nicola Weidner
- Department of Radiation Oncology, University Hospital, Tübingen, Germany
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy Cancer Centre, Villejuif, France
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Georges Noel
- Department of Radiation Oncology, Centre Paul Strauss, Strasbourg, France
| | - Mariacarla Valli
- Department of Radiation Oncology, Sant Anna Hospital, Como, Italy
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Eveline Koiter
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Severine Racadot
- Department of Radiation Oncology, Centre Léon Bérard, Lyon, France
| | | | - Harry Bartelink
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk Struikmans
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Philip M Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
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11
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Suk Chang J, Ko H, Hee Im S, Sung Kim J, Kyung Byun H, Bae Kim Y, Jung W, Park G, Sun Lee H, Sung W, Olson R, Hong CS, Kim K. Incorporating axillary-lateral thoracic vessel juncture dosimetric variables improves model for predicting lymphedema in patients with breast cancer: A validation analysis. Clin Transl Radiat Oncol 2023; 41:100629. [PMID: 37131951 PMCID: PMC10149196 DOI: 10.1016/j.ctro.2023.100629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023] Open
Abstract
Background A relationship between the axillary-lateral thoracic vessel juncture (ALTJ) dose and lymphedema rate has been reported in patients with breast cancer. The purpose of this study was to validate this relationship and explore whether incorporation of the ALTJ dose-distribution parameters improves the prediction model's accuracy. Methods A total of 1,449 women with breast cancer who were treated with multimodal therapies from two institutions were analyzed. We categorized regional nodal irradiation (RNI) as limited RNI, which excluded level I/II, vs extensive RNI, which included level I/II. The ALTJ was delineated retrospectively, and dosimetric and clinical parameters were analyzed to determine the accuracy of predicting the development of lymphedema. Decision tree and random forest algorithms were used to construct the prediction models of the obtained dataset. We used Harrell's C-index to assess discrimination. Results The median follow-up time was 77.3 months, and the 5-year lymphedema rate was 6.8 %. According to the decision tree analysis, the lowest lymphedema rate (5-year, 1.2 %) was observed in patients with ≤ six removed lymph nodes and ≤ 66 % ALTJ V35Gy. The highest lymphedema rate was observed in patients with > 15 removed lymph nodes and an ALTJ maximum dose (Dmax) of > 53 Gy (5-year, 71.4 %). Patients with > 15 removed lymph nodes and an ALTJ Dmax ≤ 53 Gy had the second highest rate (5-year, 21.5 %). All other patients had relatively minor differences, with a rate of 9.5 % at 5 years. Random forest analysis revealed that the model's C-index increased from 0.84 to 0.90 if dosimetric parameters were included instead of RNI (P <.001). Conclusion The prognostic value of ALTJ for lymphedema was externally validated. The estimation of lymphedema risk based on individual dose-distribution parameters of the ALTJ seemed more reliable than that based on the conventional RNI field design.
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Affiliation(s)
- Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
- Corresponding authors.
| | - Heejoo Ko
- College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Sang Hee Im
- Department and Research Institute of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
| | - Wonguen Jung
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Republic of Korea
| | - Goeun Park
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Republic of Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Republic of Korea
| | - Wonmo Sung
- Department of Biomedical Engineering and of Biomedicine & Health Sciences, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Robert Olson
- British Columbia Cancer Agency - Centre for the North, Prince George, BC, Canada
| | - Chae-Seon Hong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Republic of Korea
- Corresponding authors.
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12
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Risk-Adapted Target Delineation for Breast Cancer: Controversies and Considerations. Pract Radiat Oncol 2023; 13:e115-e120. [PMID: 36748210 DOI: 10.1016/j.prro.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 12/13/2022]
Abstract
The advent of computed tomography-based planning coupled with modern tools for target delineation and hypofractionated treatment schedules has increased efficiency and throughput for patients with breast cancer. While the benefit of adjuvant radiation therapy (RT) in reducing locoregional recurrences is established, disentangling local versus regional recurrence risks with modern treatment protocols has become an area of active research to de-escalate treatment. Delineation guidelines for nodal regions either attempt to replicate results of conventional RT techniques by translating bony landmarks to clinical target volumes or use landmarks based on the fact that lymphatic channels run along the vasculature. Because direct comparisons of both approaches are implausible, mapping studies of nodal recurrences have reported on the proportion of nodes included in these delineation guidelines, and larger, bony, landmark-based guidelines appear intuitively appealing for patients with unfavorable risk factors. A pooled analysis of these studies is reported here, along with literature supporting the exclusion of the true chest wall from postmastectomy/breast-conserving surgery clinical target volumes and the selective (versus routine) use of bolus during postmastectomy RT. The risk-adapted approach suggested here accounts for the risk of recurrence as well as toxicity and endorses nuanced target volume delineation rather than a one-size-fits-all approach.
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13
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Song YC, Kong J, Li N, Liu XL, Li XH, Zhu LY, Wang YW, Fang H, Jing H, Tang Y, Li YX, Wang XH, Zhang J, Wang SL. Comparison of supraclavicular surgery plus radiotherapy versus radiotherapy alone in breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastasis: a multicenter retrospective study. Radiother Oncol 2023; 183:109639. [PMID: 36990395 DOI: 10.1016/j.radonc.2023.109639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/27/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE To evaluate and compare the outcomes of supraclavicular lymph node dissection plus radiotherapy (RT) and RT alone for patients with synchronous ipsilateral supraclavicular lymph node metastasis. METHODS In all, 293 patients with synchronous ipsilateral supraclavicular lymph node metastasis across three centers were included. Of these, 85 (29.0%) received supraclavicular lymph node dissection plus RT (Surgery + RT) and 208 (71.0%) received RT alone. All patients received preoperative systemic therapy followed by mastectomy or lumpectomy and axillary dissection. Supraclavicular recurrence-free survival (SCRFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were evaluated by using the Kaplan-Meier method and multivariate Cox models. Multiple imputation was used for missing data. RESULTS The median follow-up duration of the RT and Surgery + RT groups were 53.7 and 63.5 months, respectively. For the RT and Surgery + RT groups, the 5-year SCRFS rates were 91.7% vs. 85.5% (P=0.522), LRRFS rates were 79.1% vs. 73.1% (P=0.412), DMFS rates were 60.4 vs. 58.8% (P=0.708), DFS rates were 57.6% vs. 49.7% (P=0.291), and OS rates were 71.9% vs. 62.2% (P=0.272), respectively. There was no significant effect on any outcome when comparing Surgery +RT versus RT alone in the multivariate analysis. Based on four risk factors of DFS, patients were classified into three risk groups: the intermediate- and high-risk groups had significantly lower survival outcomes than the low-risk group. Surgery +RT did not improve outcomes of any risk group compared with RT alone. CONCLUSIONS Patients with synchronous ipsilateral supraclavicular lymph node metastasis may not benefit from supraclavicular lymph node dissection. Distant metastasis remained the major failure pattern, especially for intermediate- and high-risk groups.
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Marks LB, Pierce LJ, Buchholz TA, Haffty BG. Nailing the Clavicular Head: Assuring Adequate Coverage of the Medial/Inferior Aspect of the Supraclavicular Space in Patients Receiving Regional Nodal Radiation Therapy for Breast Cancer. Pract Radiat Oncol 2023; 13:e121-e125. [PMID: 36748209 DOI: 10.1016/j.prro.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/29/2022] [Accepted: 10/01/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Lori J Pierce
- Rogel Cancer Center, University of Michigan School of Medicine, Ann Arbor, Michigan
| | | | - Bruce G Haffty
- Deptartment Radiation Oncology, Rutgers Robert Wood Johnson and New Jersey Medical Schools, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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15
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Jayatilaka A, Lokhandwala A, Manouchehri K, Brackstone M, Lock M. Are Radiation Target Volumes for Postmastectomy Radiation Therapy Too Large? Initial Report of the Complication Avoidance of Reconstruction Implant Radiation Therapy (CARIT) Study. Curr Oncol 2023; 30:2271-2276. [PMID: 36826136 PMCID: PMC9954939 DOI: 10.3390/curroncol30020175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/10/2023] [Accepted: 02/11/2023] [Indexed: 02/16/2023] Open
Abstract
Following mastectomy for breast cancer, women may choose implant-based reconstruction for many reasons, such as cosmesis, self-identity, and the ability to wear particular items of clothing. However, postmastectomy radiation therapy (PMRT) can compromise these cosmetic goals, including as much as a 40% loss of implant rate. To minimize the risk of radiation toxicity, it is important to consider how clinical target volumes (CTVs) can be optimized in PMRT to preserve the implant and reduce complications. Typically, guidelines from organizations such as the Radiation Oncology Group are used, which include regions previously encompassed by tangential fields. This includes all structures below the pectoralis muscle, such as the chest wall, where the risk of recurrence is negligible; this technique often requires incidental inclusion of portions of the lung and heart plus circumferential radiation of the implant. We present the preliminary single institution case series of a technique of complication avoidance of reconstruction implant radiation therapy, called CARIT, where the chest wall, and a large proportion of the implant, is not irradiated. In a retrospective review of 30 cases in which CARIT has been attempted, it was found that 24% of patients treated required a second surgery due to Baker grade III/IV capsular contracture. Using the Modified Harvard Harris Cosmetic Scale, 66.5% of patients had cosmetic outcomes rated as "good" or "excellent". CARIT could offer a technique to reduce complications in postmastectomy implant-based reconstruction patients, with our next steps focusing on improving dosimetry, and formally comparing the cosmesis and tumor control aspects with commonly used techniques.
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Affiliation(s)
- Aruni Jayatilaka
- Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Ashira Lokhandwala
- Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Kimya Manouchehri
- Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Muriel Brackstone
- Department of Oncology, London Regional Cancer Program, London, ON N6A 5W9, Canada
- Division of General Surgery, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Michael Lock
- Department of Oncology, London Regional Cancer Program, London, ON N6A 5W9, Canada
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16
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Cho WK, Park W, Jeong Y, Kim H, Kim N. Patterns of regional recurrence according to molecular subtype in patients with pN2 breast cancer treated with limited field regional irradiation. Jpn J Clin Oncol 2023; 53:57-62. [PMID: 36305299 DOI: 10.1093/jjco/hyac161] [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: 08/16/2022] [Accepted: 09/28/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE There is little evidence regarding the radiotherapy modification based on molecular subtypes in breast cancer. This study aimed to identify the risk and patterns of regional recurrence according to molecular subtype in patients with pN2 breast cancer. METHODS We identified 454 patients who underwent radical surgery for breast cancer with 4-9 axillary lymph node metastases. All patients underwent axillary lymph node dissection, adjuvant chemotherapy and limited-field regional nodal irradiation. The rates and patterns of regional recurrence were compared between the following three subgroups: luminal type (estrogen receptor- and/or progesterone receptor-positive), HER2-type (estrogen receptor- and progesterone receptor-negative and HER2-positive) and triple-negative type (estrogen receptor-, progesterone receptor- and HER2-negative). RESULTS Regional recurrence occurred in 18/454 patients (4%). The risk of regional recurrence was higher in the triple-negative (hazard ratio 7.641) and HER2-type (hazard ratio 4.032) subtypes than in the luminal subtype. The predominant pattern of regional recurrence was inside the radiotherapy field in triple-negative breast cancer and outside the radiotherapy field in HER2-type and luminal-type cancers. CONCLUSIONS In patients with pN2 breast cancer, the risk of regional recurrence was higher in the triple-negative and HER2-type than in the luminal type. In-field recurrence was predominant in triple-negative cancer, while out-field recurrence was frequent in luminal and HER2-type breast cancers.
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Affiliation(s)
- Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yuri Jeong
- Department of Radiation Oncology, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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17
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Zhao XR, Fang H, Jing H, Tang Y, Song YW, Liu YP, Jin J, Chen B, Qi SN, Tang Y, Lu NN, Li N, Li YX, Wang SL. Radiation-Induced Hypothyroidism in Patients With Breast Cancer After Hypofractionated Radiation Therapy: A Prospective Cohort Study. Int J Radiat Oncol Biol Phys 2023; 115:83-92. [PMID: 36306978 DOI: 10.1016/j.ijrobp.2022.04.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/04/2022] [Accepted: 04/07/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Our objective was to assess the incidence and risk factors of radiation-induced hypothyroidism (RHT) after adjuvant hypofractionated radiation therapy (RT) in patients with breast cancer. METHODS AND MATERIALS Eligible patients with breast cancer who were treated with hypofractionated RT were prospectively evaluated. Thyroid function tests were performed before and at regular times after RT. RHT was defined as twice elevated serum thyroid-stimulating hormone (TSH) with decreased or normal free thyroxin after RT. The patient, tumor, and treatment factors were evaluated for possible associations with the risk of RHT. RESULTS Five hundred patients were analyzed. All patients underwent chest wall/breast with or without regional nodal irradiation. Among them, 369 (73.8%) patients received supraclavicular nodal radiation (SCRT). Eighty-two (16.4%) patients had elevated TSH before RT. At a median follow-up of 21.9 months, 131 (26.2%) patients developed RHT, and 59 (11.8%) patients received thyroid hormone-replacement therapy. Patients with SCRT had a significantly increased 2-year cumulative incidence of RHT compared with patients without SCRT (31.5% and 11.4%, P<.001). The peak incidence of RHT occurred around 6 to 12 months after RT. Multivariate analysis revealed that elevated baseline TSH and increased thyroid mean dose (Dmean) were independent risk factors for developing RHT. After adjusted for baseline TSH, there was a nonlinear relationship between thyroid Dmean and the risk of RHT. Dmean >21 Gy was the threshold value for predicting RHT (hazard ratio, 2.2; P<.001). CONCLUSIONS The incidence of RHT was high in patients with breast cancer. Thyroid function test should be started no later than 6 months after RT. We recommend that the Dmean of the thyroid should be kept lower than 21 Gy for hypofractionated RT.
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Affiliation(s)
- Xu-Ran Zhao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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18
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Telarovic I, Yong CSM, Guckenberger M, Unkelbach J, Pruschy M. Radiation-induced lymphopenia does not impact treatment efficacy in a mouse tumor model. Neoplasia 2022; 31:100812. [PMID: 35667149 PMCID: PMC9168138 DOI: 10.1016/j.neo.2022.100812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 12/03/2022]
Abstract
Radiation-induced lymphopenia is a common occurrence in radiation oncology and an established negative prognostic factor, however the mechanisms underlying the relationship between lymphopenia and inferior survival remain elusive. The relevance of lymphocyte co-irradiation as critical normal tissue component at risk is an emerging topic of high clinical relevance, even more so in the context of potentially synergistic radiotherapy-immunotherapy combinations. The impact of the radiotherapy treatment volume on the lymphocytes of healthy and tumor-bearing mice was investigated in a novel mouse model of radiation-induced lymphopenia. Using an image-guided small-animal radiotherapy treatment platform, translationally relevant tumor-oriented volumes of irradiation with an anatomically defined increasing amount of normal tissue were irradiated, with a focus on the circulating blood and lymph nodes. In healthy mice, the influence of irradiation with increasing radiotherapy treatment volumes was quantified on the level of circulating blood cells and in the spleen. A significant decrease in the lymphocytes was observed in response to irradiation, including the minimally irradiated putative tumor area. The extent of lymphopenia correlated with the increasing volumes of irradiation. In tumor-bearing mice, differential radiotherapy treatment volumes did not influence the overall therapeutic response to radiotherapy alone. Intriguingly, an improved treatment efficacy in mice treated with draining-lymph node co-irradiation was observed in combination with an immune checkpoint inhibitor. Taken together, our study reveals compelling data on the importance of radiotherapy treatment volume in the context of lymphocytes as critical components of normal tissue co-irradiation and highlights emerging challenges at the interface of radiotherapy and immunotherapy.
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Affiliation(s)
- Irma Telarovic
- Laboratory for Applied Radiobiology, Dept. Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Carmen S M Yong
- Laboratory for Applied Radiobiology, Dept. Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Dept. Immunology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias Guckenberger
- Dept. Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jan Unkelbach
- Dept. Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Martin Pruschy
- Laboratory for Applied Radiobiology, Dept. Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
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19
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Bazan JG, Khan AJ. Target Volume Delineation and Patterns of Recurrence in the Modern Era. Semin Radiat Oncol 2022; 32:254-269. [DOI: 10.1016/j.semradonc.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Entire versus Medial Supraclavicular Nodal Irradiation for Patients with High-risk Node-positive Breast Cancer. Int J Radiat Oncol Biol Phys 2022; 114:120-129. [DOI: 10.1016/j.ijrobp.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/09/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022]
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21
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Turna M, Rzazade R, Canoğlu MD, Küçükmorkoç E, Küçük N, Çağlar HB. Evaluation of clinically involved lymph nodes with deformable registration in breast cancer radiotherapy. Br J Radiol 2022; 95:20211234. [PMID: 35084214 PMCID: PMC10993962 DOI: 10.1259/bjr.20211234] [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: 11/09/2021] [Revised: 12/21/2021] [Accepted: 01/12/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Modern radiotherapy (RT) techniques require careful delineation of the target. There is no particular RT contouring guideline for patients receiving neoadjuvant chemotherapy (NACT). In this study, we examined the distribution of pre-chemotherapy clinically positive nodal metastases. METHODS We explored the coverage rate of the RTOG breast contouring guideline by deformable fusion of 18-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) scan. We retrospectively evaluated neoadjuvant chemotherapy patients. All PET-CT images were imported into the planning software. We combined the planning CT and the CT images of PET-CT with rigid and then a deformable registration. We manually contoured positive lymph nodes on the CT component of the PET-CT data set and transferred them to planning CT after fusion. We evaluated whether previously contoured lymphatic CTVs, according to the RTOG breast atlas, include GTV-LNs. RESULTS All breast cancer patients between October 2018 and February 2021 were evaluated from the electronic database. There were 142 radiologically defined positive lymph nodes in 31 patients who were irradiated after NACT. Most LNs (70%) were in the level I axilla. Only 71.1% (n:101) of the whole lymph nodes in 10 patients were totally covered, 22.5% (n:32) partially covered and 6.4% %(n:9) totally undercovered. CONCLUSIONS The extent of regional nodal areas in the RTOG atlas may be insufficient to cover positive lymph nodes adequately. For patients with nodal involvement undergoing neoadjuvant chemotherapy, PET-CT image fusions can be helpful to be sure that positive lymph nodes are in the treatment volume. ADVANCES IN KNOWLEDGE RTOG contouring atlas may be insufficient to cover all involved lymph nodes after NACT. For patients with nodal involvement undergoing neoadjuvant chemotherapy, PET-CT image fusions may help to be sure that positive lymph nodes are in the treatment volume.
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Affiliation(s)
- Menekse Turna
- Department of Radiation Oncology, Anadolu Medical
Center, Gebze, Kocaeli,
Turkey
| | - Rashad Rzazade
- Department of Radiation Oncology, Anadolu Medical
Center, Gebze, Kocaeli,
Turkey
| | - Mehmet Doğu Canoğlu
- Department of Radiation Oncology, Anadolu Medical
Center, Gebze, Kocaeli,
Turkey
| | - Esra Küçükmorkoç
- Department of Radiation Oncology, Anadolu Medical
Center, Gebze, Kocaeli,
Turkey
| | - Nadir Küçük
- Department of Radiation Oncology, Anadolu Medical
Center, Gebze, Kocaeli,
Turkey
| | - Hale Başak Çağlar
- Department of Radiation Oncology, Anadolu Medical
Center, Gebze, Kocaeli,
Turkey
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22
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Malouff TD, Vallow LA, Magalhaes WL, Seneviratne DS, Waddle MR, Tzou KS. Dosimetric Analysis of Axillary Lymph Node Coverage Using High Tangents in the Prone Position for Left-Sided Breast Cancers. Cureus 2022; 14:e23613. [PMID: 35505718 PMCID: PMC9053363 DOI: 10.7759/cureus.23613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/05/2022] Open
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23
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Mapping of Level I Axillary Lymph Nodes in Patients with Newly Diagnosed Breast Cancer: Optimal Target Delineation and Treatment Techniques for Breast and Level I Axilla irradiation. Pract Radiat Oncol 2022; 12:487-495. [PMID: 35247622 DOI: 10.1016/j.prro.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/03/2021] [Accepted: 02/14/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE To map the locations of level I axilla (Ax-L1) lymph nodes (LNs), evaluate the clinical target volume (CTV) coverage defined by the Radiation Therapy Oncology Group (RTOG) breast cancer atlas, and assess the optimal techniques for whole-breast and Ax-L1 irradiation (WBI + Ax-L1). MATERIALS AND METHODS We identified 76 newly diagnosed breast cancer patients with 1-4 positive LNs confirmed by axillary dissection. The locations of 116 involved Ax-L1 LNs on diagnostic computed tomography (CT) were mapped onto simulated CT images of a standard patient. Ax-L1 LN coverage by the RTOG atlas was evaluated, and a modified Ax-L1 CTV with better coverage was proposed. Treatment plans were designed for WBI + Ax-L1 with high tangential simplified intensity-modulated radiation therapy (HT-sIMRT) and volumetric modulated arc therapy (VMAT), and for WBI + RTOG Ax-L1 with VMAT with a prescription dose of 50 Gy in 25 fractions, respectively. The differences in dosimetric parameters were compared. RESULTS The RTOG atlas missed 29.3% of LNs. Modification by extending 1 cm caudal and 0.5 cm anterior to the RTOG-defined CTV borders allowed the modified Ax-L1 CTV to encompass 90.5% of LNs. All plans met the required prescription dose to WBI and Ax-L1. The mean dose and V20 and V5 of the ipsilateral lung were 11.7Gy, 23.0%, 38.1% for HT-sIMRT WBI + Ax-L1, and 8.9 Gy, 16.4%, 32.5% for VMAT WBI + Ax-L1 plans, respectively. The mean heart doses in the left-sided plans were 3.2Gy and 3.0Gy, respectively. The V30 of the humeral head and minimum dose to the axillary-lateral thoracic vessel junction were 2.0% vs 1.8%, and 45.5Gy vs 45.7Gy for VMAT WBI + Ax-L1 and VMAT WBI + RTOG Ax-L1 plans, respectively. CONCLUSIONS A modified Ax-L1 CTV with expansion of the caudal and anterior borders might provide better coverage. Compared with HT-sIMRT WBI + Ax-L1, VMAT WBI+ Ax-L1 provided an adequate dose to Ax-L1 with decreasing the doses to most normal tissues. Coverage of modified Ax-L1 did not increase the dose to organs-at-risk compared with coverage of RTOG Ax-L1.
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24
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Choi MS, Chang JS, Park RH, Kwon YJ, Kim YB, Moon JY, Yang G, Kim J, Kim JS. Heart-sparing Capability and Positional Reproducibility of Continuous Positive Airway Pressure in Left-sided Breast Radiation Therapy. Pract Radiat Oncol 2022; 12:e368-e375. [DOI: 10.1016/j.prro.2021.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/05/2021] [Accepted: 12/29/2021] [Indexed: 01/01/2023]
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25
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Hennequin C, Belkacémi Y, Bourgier C, Cowen D, Cutuli B, Fourquet A, Hannoun-Lévi JM, Pasquier D, Racadot S, Rivera S. Radiotherapy of breast cancer. Cancer Radiother 2021; 26:221-230. [PMID: 34955414 DOI: 10.1016/j.canrad.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Adjuvant radiotherapy is an essential component of the treatment of breast cancer. After conservative surgery for an infiltrating carcinoma, radiotherapy must be systematically performed, regardless of the characteristics of the disease, because it decreases the rate of local recurrence and by this way, specific mortality. A boost dose over the tumour bed is required if the patient is younger than 50 years-old. Partial breast irradiation could be routinely proposed as an alternative to whole breast irradiation, but only in selected and informed patients. For ductal carcinoma in situ, adjuvant radiotherapy must be also systematically performed after lumpectomy. After mastectomy, chest wall irradiation is required for pT3-T4 tumours and if there is an axillary nodal involvement, whatever the number of involved lymph nodes. After neoadjuvant chemotherapy and mastectomy, in case of pN0 disease, chest wall irradiation is recommended if there is a clinically or radiologically T3-T4 or node positive disease before chemotherapy. Axillary irradiation is recommended only if there is no axillary surgical dissection and a positive sentinel lymph node. Supra- and infraclavicular irradiation is advised in case of positive axillary nodes. Internal mammary irradiation must be discussed case by case, according to the benefit/risk ratio (cardiac toxicity). Hypofractionation regimens (42.5Gy in 16 fractions, or 41,6Gy en 13 or 40Gy en 15) are equivalent to conventional irradiation and must prescribe after tumorectomy in selected patients. Delineation of the breast, the chest wall and the nodal areas are based on clinical and radiological evaluations. 3D-conformal irradiation is the recommended technique, intensity-modulated radiotherapy must be proposed only in specific clinical situations. Respiratory gating could be useful to decrease the cardiac dose. Concomitant administration of chemotherapy in unadvised, but hormonal treatment could be start with or after radiotherapy.
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Affiliation(s)
- C Hennequin
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Y Belkacémi
- Hôpital Henri-Mondor, AP-HP, 94000 Créteil, France
| | - C Bourgier
- Institut du cancer Montpellier (ICM), 34000 Montpellier, France
| | - D Cowen
- Hôpital La Timone, AP-HM, 13000 Marseille, France
| | - B Cutuli
- Polyclinique Courlancy, 51000 Reims, France
| | - A Fourquet
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - J-M Hannoun-Lévi
- Centre Antoine-Lacassagne, 33, avenue Valombrose, 06000 Nice, France
| | - D Pasquier
- Centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - S Racadot
- Centre Léon-Bérard, 69000 Lyon, France
| | - S Rivera
- Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
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26
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Stouthandel MEJ, Kayser F, Vakaet V, Khoury R, Deseyne P, Monten C, Schoepen M, Remouchamps V, De Caluwé A, Janoray G, De Neve W, Mazy S, Veldeman L, Van Hoof T. Delineation guidelines for the lymphatic target volumes in 'prone crawl' radiotherapy treatment position for breast cancer patients. Sci Rep 2021; 11:22529. [PMID: 34795352 PMCID: PMC8602302 DOI: 10.1038/s41598-021-01841-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 11/01/2021] [Indexed: 12/15/2022] Open
Abstract
Our recently developed prone crawl position (PCP) for radiotherapy of breast cancer patients with lymphatic involvement showed promising preliminary data and it is being optimized for clinical use. An important aspect in this process is making new, position specific delineation guidelines to ensure delineation (for treatment planning) is uniform across different centers. The existing ESTRO and PROCAB guidelines for supine position (SP) were adapted for PCP. Nine volunteers were MRI scanned in both SP and PCP. Lymph node regions were delineated in SP using the existing ESTRO and PROCAB guidelines and were then translated to PCP, based on the observed changes in reference structure position. Nine PCP patient CT scans were used to verify if the new reference structures were consistently identified and easily applicable on different patient CT scans. Based on these data, a team of specialists in anatomy, CT- and MRI radiology and radiation oncology postulated the final guidelines. By taking the ESTRO and PROCAB guidelines for SP into account and by using a relatively big number of datasets, these new PCP specific guidelines incorporate anatomical variability between patients. The guidelines are easily and consistently applicable, even for people with limited previous experience with delineations in PCP.
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Affiliation(s)
- Michael E J Stouthandel
- Department of Human Structure and Repair, Ghent University, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium.
| | - Françoise Kayser
- Department of Radiology, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Vincent Vakaet
- Department of Human Structure and Repair, Ghent University, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium
| | - Ralph Khoury
- Department of Radiology, Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Pieter Deseyne
- Department of Human Structure and Repair, Ghent University, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium
| | - Chris Monten
- Department of Human Structure and Repair, Ghent University, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium
| | - Max Schoepen
- Department of Human Structure and Repair, Ghent University, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium
| | - Vincent Remouchamps
- Department of Radiotherapy, CHU UCL Namur, site Ste Elisabeth, Place Louise Godin 15, 5000, Namur, Belgium
| | - Alex De Caluwé
- Department of Radiation Oncology, Institut Jules Bordet - Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Guillaume Janoray
- Department of Radiation Oncology, Institut Jules Bordet - Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Wilfried De Neve
- Department of Human Structure and Repair, Ghent University, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium
| | - Stephane Mazy
- Department of Radiology, CHU-UCL Namur, site Ste Elisabeth, Place Louise Godin 15, 5000, Namur, Belgium
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium
| | - Tom Van Hoof
- Department of Human Structure and Repair, Ghent University, C. Heymanslaan 10, Radiotherapy park, entrance 98, 9000, Ghent, Belgium
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27
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Kaidar-Person O, Offersen BV, Boersma L, Meattini I, Dodwell D, Wyld L, Aznar M, Major T, Kuehn T, Strnad V, Palmu M, Hol S, Poortmans P. Tricks and tips for target volume definition and delineation in breast cancer: Lessons learned from ESTRO breast courses. Radiother Oncol 2021; 162:185-194. [PMID: 34302915 DOI: 10.1016/j.radonc.2021.07.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
Delineation of target and 'organ at risk' volumes is a critical part of modern radiation therapy planning, the next essential step after deciding the indication, patient discussion and image acquisition. Adoption of volume-based treatment planning for non-metastatic breast cancer has increased greatly along with the use of improved planning techniques, essential for modern therapy. However, identifying the volumes on a planning CT is no easy task. The current paper is written by ESTRO's breast course faculty, providing tricks and tips for target volume definition and delineation for optimal postoperative breast cancer irradiation.
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Affiliation(s)
- Orit Kaidar-Person
- Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Israel.
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Liesbeth Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, The Netherlands
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, UK
| | - Marianne Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary & Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Thorsten Kuehn
- Department of Gynaecology and Obstetrics, Interdisciplinary Breast Center, Klinikum Esslingen, Germany
| | - Vratislav Strnad
- Dept. of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Miika Palmu
- European SocieTy for Radiotherapy and Oncology, UK
| | - Sandra Hol
- Instituut Verbeeten, Tilburg, The Netherlands
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28
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DeCesaris CM, Mossahebi S, Jatczak J, Rao AD, Zhu M, Mishra MV, Nichols E. Outcomes of and treatment planning considerations for a hybrid technique delivering proton pencil-beam scanning radiation to women with metal-containing tissue expanders undergoing post-mastectomy radiation. Radiother Oncol 2021; 164:289-298. [PMID: 34280402 DOI: 10.1016/j.radonc.2021.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Following mastectomy, immediate breast reconstruction often involves the use of temporary tissue expanders (TEs). TEs contain metallic ports (MPs), which complicate proton pencil-beam scanning (PBS) planning. A technique was implemented for delivering PBS post-mastectomy radiation (PMRT) to patients with TEs and MPs. METHODS A protocol utilizing a hybrid single- and multi-field optimization (SFO, MFO) technique was developed. Plans were robustly optimized using a Monte Carlo algorithm. A CTV_eval structure including chest wall (CW) and regional nodal (RNI) targets and excluding the TE was evaluated. Organ at risk (OAR) dosimetry and acute toxicities were analyzed. RESULTS Twenty-nine women were treated with this technique. A 2-field SFO technique was used superior and inferior to the MP, with a 3 or 4-field MFO technique used at the level of the MP. Virtual blocks were utilized so that beams did not travel through the MP. A port-to-CW distance of 1 cm was required. Patients underwent daily image-guidance to ensure the port remained within a 0.5 cm internal planning volume (ITV). Median RT dose to CTV_eval was 50.4 Gy (45.0-50.4). Median 95% CTV_eval coverage was 99.5% (95-100). Optically stimulated luminescent dosimeter (OSLD) readings were available for 8 patients and correlated to the dose measurements in the treatment planning system (TPS); median OSLD ratio was 0.99 (range, 0.93-1.02). CONCLUSIONS Delivering PMRT with PBS for women with metal-containing TEs using a hybrid SFO/MFO technique is feasible, reproducible, and achieves excellent dose distributions. Specialized planning and image-guidance techniques are required to safely utilize this treatment in the clinic.
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Affiliation(s)
- Cristina M DeCesaris
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, United States.
| | - Sina Mossahebi
- Division of Physics, Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, United States
| | - Jenna Jatczak
- Maryland Proton Treatment Center, Baltimore, United States
| | - Avani D Rao
- Department of Radiation Oncology, Inova Schar Cancer Institute, Fairfax, United States
| | - Mingyao Zhu
- Department of Radiation Oncology, Emory University, Atlanta, United States
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, United States
| | - Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, United States
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Choi SH, Chang JS, Byun HK, Son NH, Hong CS, Hong N, Park Ms YI, Kim J, Kim JS, Kim YB. Risk of Hypothyroidism in Women After Radiation Therapy for Breast Cancer. Int J Radiat Oncol Biol Phys 2021; 110:462-472. [PMID: 33412261 DOI: 10.1016/j.ijrobp.2020.12.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 12/19/2020] [Accepted: 12/28/2020] [Indexed: 01/17/2023]
Abstract
PURPOSE To study the hypothyroidism risk after adjuvant radiation therapy (RT) and the association of different RT targets with hypothyroidism risk. METHODS We studied 4073 women treated with adjuvant RT for breast cancer from 2007 to 2016. The primary endpoint was hypothyroidism development after RT. Patients were divided and analyzed into 3 groups: whole breast (WB)-alone (n = 2468), regional node irradiation (RNI)-Lv.4 (n = 215; cranial border at the subclavian artery, according to the European Society for Radiotherapy and Oncology consensus guideline), and RNI-supraclavicular lymph node (SCL) (n = 1390; cranial border at the cricoid cartilage). In general, RNI-Lv.4 was used in the patients with high-risk pN0 and pN1 breast cancer. In auxiliary analysis, the mean thyroid dose was estimated in each group (total n = 600, 200 from each group). All the doses were converted to the equivalent dose in 2 Gy fractions (EQD2) with α/β ratios of 3. RESULTS The median follow-up duration was 84 months (WB-alone, 84 months; RNI-Lv.4, 44 months; RNI-SCL, 91 months). The 3-year hypothyroidism incidence rate differed significantly between the RNI-SCL and WB-alone groups (2.2% vs 0.8%; Bonferroni corrected P [Pc] < .001) but not between the RNI-Lv.4 and WB-alone groups (0.9% vs 0.8%; Pc > .05). The Cox model revealed an adjusted hazard ratio of 2.25 (95% CI, 1.49-3.38) for RNI-SCL vs WB-alone, 1.69 (95% CI, 1.12-2.56) for adjuvant systemic therapies, and 2.07 (95% CI, 1.07-3.99) for age <60 years. In the subgroup analysis, the hypothyroidism risk became more prominent in patients aged <60 years. The mean exposure doses to the thyroid were 0.23 versus 1.93 versus 7.89 Gy (EQD2) for the WB-alone versus RNI-Lv.4 versus RNI-SCL groups (P < .001). No statistically different locoregional recurrence rates were seen between groups (5-year rate: <3%). CONCLUSIONS The risk of hypothyroidism increases after RNI-SCL for breast cancer but not after RNI-Lv 4. These data support routine contouring of the thyroid in the RNI setting, and future studies are required to develop optimal dose-volume constraints.
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Affiliation(s)
- Seo Hee Choi
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea.
| | - Hwa Kyung Byun
- Data Science Team, Center for Digital Health, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Nak-Hoon Son
- Data Science Team, Center for Digital Health, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Chae-Seon Hong
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ye-In Park Ms
- Department of Radiation Oncology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Gyeonggi-do, Republic of Korea
| | - Jihun Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
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30
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Liang JA, Lee PC, Ku CP, Chen WTL, Chung CY, Kuo YC, Chou SH, Li CC, Chien CR. Effectiveness of Image-Guided Radiotherapy in Adjuvant Radiotherapy on Survival for Localized Breast Cancer: A Population-Based Analysis. Cancer Manag Res 2021; 13:3465-3472. [PMID: 33907469 PMCID: PMC8069678 DOI: 10.2147/cmar.s299975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/13/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose Image-guided radiotherapy (IGRT) is an advanced radiotherapy technique to improve the radiotherapy delivery. We aimed to compare the overall survival (OS) for localized breast cancer (LBC) patient treated with adjuvant conventional fractionated radiotherapy (CFRT) using IGRT vs those without IGRT via a population-based analysis. Patients and Methods Eligible LBC patients diagnosed between 2011 and 2013 were identified via the Taiwan Cancer Registry. We used propensity score (PS) weighting to balance observable potential confounders between groups. The hazard ratio (HR) of death and other outcomes were compared between IGRT and non-IGRT. We also evaluated OS in various supplementary analyses. Results Our primary analysis included 6490 patients in whom covariates were well balanced after PS weighing. The HR for death when IGRT was compared with non-IGRT was 1.02 (95% confidence interval 0.80–1.31, P = 0.86). There were also no significant differences in the supplementary analyses. Conclusion We found that OS of LBC patients treated with adjuvant CFRT was not statistically different between those treated with IGRT versus without IGRT. This was the first study in this regard to our knowledge but randomized controlled trials were needed to confirm our finding.
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Affiliation(s)
- Ji-An Liang
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Po-Chang Lee
- Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Chun-Ping Ku
- Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - William Tzu-Liang Chen
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Chih-Yuan Chung
- Department of Medical Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Yu-Cheng Kuo
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Szu-Hsien Chou
- Department of Medical Imaging, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Chia-Chin Li
- Department of Radiation Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Chun-Ru Chien
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan.,School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Radiation Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
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31
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Ahmad I, Chufal KS, Bhatt CP, Miller AA, Bajpai R, Chowdhary RL, Pahuja AK, Chhabra A, Gairola M. Can the Choice of Radiotherapy Delivery Technique Influence Which Target Delineation Protocol to Use? A Plan-Quality-Based Analysis in Left Breast Cancer. ASIAN JOURNAL OF ONCOLOGY 2020. [DOI: 10.1055/s-0040-1722428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Abstract
Introduction This study investigates the optimal target delineation protocol stratified by treatment planning technique in patients undergoing whole breast radiotherapy after breast conservation surgery.
Materials and Methods Target delineation using Tangent (RTOG 0413 Whole Breast Irradiation Protocol), European SocieTy for Radiotherapy and Oncology (ESTRO), and Radiation Therapy & Oncology Group (RTOG) guidelines was performed on 10 randomly selected treatment planning computed tomography datasets of patients with left-sided breast cancer. An objective plan quality metric (PQM) scoring schema was defined and communicated to the medical physicist prior to commencement of treatment planning. Treatment planning was performed using field-in-field (FiF) intensity modulated radiotherapy technique (IMRT), inverse IMRT, and volumetric modulated arc therapy (VMAT), for each type of target. Two-way repeated measures, analysis of variance was utilized to compare the total PQM scores and dosimetric variables, stratified by treatment planning method.
Results Total PQM score of plans for FiF, IMRT, and VMAT revealed that Tangent and ESTRO delineations were equivalent regardless of planning technique (Tangent vs. ESTRO for FiF, p = 0.099; Tangent vs. ESTRO for IMRT, p = 0.029; Tangent vs. ESTRO for VMAT, p = 0.438). Both delineation protocols were significantly superior to RTOG for all treatment planning techniques.
Conclusion For all treatment planning techniques, ESTRO and Tangent delineation were equivalent and both achieved significantly higher scores than RTOG delineation.
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Affiliation(s)
- Irfan Ahmad
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Kundan Singh Chufal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Chandi Prasad Bhatt
- Department of Radiation Oncology, Sarvodaya Hospital and Research Centre, Faridabad, Haryana, India
| | - Alexis Andrew Miller
- Department of Radiation Oncology, Illawarra Cancer Care Centre, Wollongong, New South Wales, Australia
| | - Ram Bajpai
- School of Medicine, Keele University, Staffordshire, United Kingdom
| | - Rahul Lal Chowdhary
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Anjali Kakria Pahuja
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Akanksha Chhabra
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
| | - Munish Gairola
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi, India
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Wang Y, Wang F. Postoperative Radiotherapy for Thoracic Esophageal Carcinoma with Upfront R0 Esophagectomy. Cancer Manag Res 2020; 12:13023-13032. [PMID: 33376396 PMCID: PMC7755334 DOI: 10.2147/cmar.s286074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/10/2020] [Indexed: 12/11/2022] Open
Abstract
Multidisciplinary therapies can improve the survival of patients with locally advanced esophageal carcinoma. However, the determination of the optimal modality is still a controversial subject. Many randomized controlled trials in the late 20th century showed that there was no survival benefit when postoperative radiotherapy was added to surgery for esophageal carcinoma. As a result, the treatment modality shifted thereafter to neoadjuvant therapies. Even so, these trials are criticized for many limitations and an increasing number of studies (mainly nonrandomized controlled trials) has indicated that postoperative radiotherapy/chemoradiotherapy can improve the survival of patients with a poor prognosis after R0 esophagectomy. Additionally, a large number of patients with locally advanced esophageal carcinoma still choose upfront surgery in the clinical practice due to many reasons. Therefore, postoperative radiotherapy seems to be a feasible treatment for these patients with a poor prognosis, particularly in the new era of conformal radiotherapy. Here, we review published studies on postoperative radiotherapy/chemoradiotherapy, and we discuss the clinical issues related to postoperative radiotherapy, such as the indication, target volume, total radiation dosage, time interval and complications of postoperative radiotherapy with or without chemotherapy, to make recommendations of postoperative radiotherapy for both current practice and future research in esophageal carcinoma.
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Affiliation(s)
- Yichun Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Fan Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, People's Republic of China
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Yaney A, Ayan AS, Pan X, Jhawar S, Healy E, Beyer S, Lindsey K, Kuhn K, Tedrick K, White JR, Bazan JG. Dosimetric parameters associated with radiation-induced esophagitis in breast cancer patients undergoing regional nodal irradiation. Radiother Oncol 2020; 155:167-173. [PMID: 33157173 DOI: 10.1016/j.radonc.2020.10.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND/PURPOSE Rates of acute esophagitis in breast cancer patients undergoing regional nodal irradiation (RNI) are under-reported. We set to identify esophageal dose-volume constraints associated with grade 2 esophagitis (G2E). We hypothesized that the G2E rate was higher with intensity modulated radiation therapy (IMRT) vs. 3D conformal radiation therapy (3DCRT). MATERIALS/METHODS We identified patients that received RNI (50 Gy/25 fractions) from 1/2013 to 6/2019. We retrospectively contoured the esophagus in a consistent manner and recorded esophageal mean dose, max dose, and V10-V50. Our primary endpoint was the G2E rate. Receiver operating characteristics curves analysis (e.g., Youden's J statistic) were used to determine the cutpoints for the dosimetric parameters which were then tested in logistic regression models. RESULTS We identified 531 patients (50% left-sided; 41% IMRT; 16.2% G2E). G2E was significantly higher in IMRT vs. 3DCRT patients (23.6% vs. 10.9%, p < 0.0001). All esophageal dosimetric parameters were significantly associated with G2E after adjusting for age and laterality. The cutpoints for esophageal mean dose, V10 and V20 were 11 Gy, 30%, and 15%, respectively. The associations between the dichotomized dose-volume parameters and G2E were OR = 3.82 (95% CI 2.28-6.40, p < 0.0001) for esophageal mean dose, OR = 5.37 (95% CI 3.01-9.58, p < 0.0001) for esophageal V10, and OR = 3.23 (95% CI 1.93-5.41, p < 0.0001) for esophageal V20. CONCLUSION In patients receiving RNI with modern techniques, we found that G2E occurs in >15%, and more frequently with IMRT. These data strongly support the routine contouring of the esophagus in RNI planning, and our constraints should be incorporated in future prospective protocols of RNI.
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Affiliation(s)
- Alexander Yaney
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Ahmet S Ayan
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Xueliang Pan
- Department of Biomedical Informatics, The Ohio State University, Columbus, USA.
| | - Sachin Jhawar
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Erin Healy
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Sasha Beyer
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Kylee Lindsey
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Karla Kuhn
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Kayla Tedrick
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Julia R White
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
| | - Jose G Bazan
- Department of Radiation Oncology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Stefanie Spielman Comprehensive Breast Center, Columbus, USA.
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Bazan JG, Healy E, Beyer S, Kuhn K, DiCostanzo D, Smith TL, Jhawar S, White JR. Clinical Effectiveness of an Adaptive Treatment Planning Algorithm for Intensity Modulated Radiation Therapy Versus 3D Conformal Radiation Therapy for Node-Positive Breast Cancer Patients Undergoing Regional Nodal Irradiation/Postmastectomy Radiation Therapy. Int J Radiat Oncol Biol Phys 2020; 108:1159-1171. [PMID: 32711036 DOI: 10.1016/j.ijrobp.2020.07.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Clinical trials support adjuvant regional nodal irradiation (RNI) after breast-conserving surgery or mastectomy for patients with lymph node-positive breast cancer. Advanced treatment planning techniques (eg, intensity modulated radiation therapy [IMRT]) can reduce dose to organs at risk (OARs) in this situation. However, uncertainty persists about when IMRT is clinically indicated (vs 3-dimensional conformal radiation therapy [3DCRT]) for RNI. We hypothesized that an adaptive treatment planning algorithm (TPA) for IMRT adoption would allow OAR constraints for RNI to be met when 3DCRT could not without significantly changing toxicity and locoregional recurrence (LRR) patterns. METHODS AND MATERIALS Since 2013, all RNI patients also underwent an adaptive TPA that began with 3DCRT and then changed to IMRT when OAR constraints (mean heart dose ≤500 cGy; ipsilateral lung V20 ≤35%) could not be met. Patients received 2 Gy/d to the prospectively contoured target volumes (including internal mammary nodes). We retrospectively evaluated the dosimetry and clinical outcomes of the treatment groups (IMRT vs 3DCRT). The primary endpoint was the cumulative incidence of LRR as the site of first recurrence, and we specifically address patterns of failure based on dose to the posterior supraclavicular nodal region (SCL-post). RESULTS Two hundred forty patients (60% stage III; mean 4.0 + nodes) underwent an adaptive-TPA for RNI after mastectomy (74%) or breast-conserving surgery (26%), resulting in 168 patients treated with 3DCRT and 72 patients treated with IMRT. There were 7 LRRs (2 IMRT, 5 3DCRT) resulting in 4-year LRR of 2.8% for IMRT versus 1.8% for 3DCRT (P = .99). Three patients (2 IMRT, 1 3DCRT) had SCL nodal failures (1 in the SCL-post). CONCLUSIONS An adaptive TPA for use of IMRT when 3DCRT does not meet critical OAR constraints resulted in rare high-grade toxicity and no difference in failure patterns between patients treated with IMRT and 3DCRT. These data should provide reassurance that IMRT maintains the therapeutic ratio by preserving cancer control outcomes without excess toxicity when 3DCRT fails to meet OAR constraints.
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Affiliation(s)
- Jose G Bazan
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio.
| | - Erin Healy
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sasha Beyer
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Karla Kuhn
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Tamara L Smith
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Sachin Jhawar
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Julia R White
- Department of Radiation Oncology, The Arthur G. James Cancer Hospital and Solove Research Institute, Ohio State University Comprehensive Cancer Center, Columbus, Ohio
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Beaton L, Nica L, Tyldesley S, Sek K, Ayre G, Aparicio M, Gondara L, Speers C, Nichol A. PET/CT of breast cancer regional nodal recurrences: an evaluation of contouring atlases. Radiat Oncol 2020; 15:136. [PMID: 32487183 PMCID: PMC7268399 DOI: 10.1186/s13014-020-01576-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/19/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND To validate the Radiation Therapy Oncology Group (RTOG) and European Society for Radiotherapy and Oncology (ESTRO) breast cancer nodal clinical target volumes (CTVs) and to investigate the Radiotherapy Comparative Effectiveness Consortium (RADCOMP) Posterior Neck volume in relation to regional nodal recurrences (RNR). METHODS From a population-based database, 69 patients were identified who developed RNR after curative treatment for breast cancer. RNRs were detected with 18-fluorodeoxyglucose-positron emission tomography-computed tomography (PET/CT). All patients were treatment-naïve for RNR when imaged. The RTOG and ESTRO nodal CTVs and RADCOMP Posterior Neck volumes were contoured onto a template patient's CT. RNRs were contoured on each PET/CT and deformed onto the template patient's CT. Each RNR was represented by a 5 mm diameter epicentre, and categorized as 'inside', 'marginal' or 'outside' the CTV boundaries. RESULTS Sixty-nine patients with 226 nodes (median 2, range 1-11) were eligible for inclusion. Thirty patients had received adjuvant tangent and regional nodal radiotherapy, 16 tangent-only radiotherapy and 23 no adjuvant radiotherapy. For the RTOG CTVs, the RNR epicentres were 70% (158/226) inside, 4% (8/226) marginal and 27% (60/226) outside. They included the full extent of the RNR epicentres in 38% (26/69) of patients. Addition of the RADCOMP Posterior Neck volume increased complete RNR coverage to 48% (33/69) of patients. For the ESTRO CTVs, the RNR epicentres were 73% (165/226) inside, 2% (4/226) marginal and 25% (57/226) outside. They included the full extent of the RNR epicentres in 57% (39/69) of patients. Addition of the RADCOMP Posterior Neck volume increased complete RNR coverage to 70% (48/69) of patients. CONCLUSIONS The RTOG and ESTRO breast cancer nodal CTVs do not fully cover all potential areas of RNR, but the ESTRO nodal CTVs provided full coverage of all RNR epicentres in 19% more patients than the RTOG nodal CTVs. With addition of the RADCOMP Posterior Neck volume to the ESTRO CTVs, 70% of patients had full coverage of all RNR epicentres.
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Affiliation(s)
- Laura Beaton
- Department of Radiation Oncology, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Luminita Nica
- Department of Radiation Oncology, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Scott Tyldesley
- Department of Radiation Oncology, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada
- Cancer Surveillance and Outcomes, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Kenny Sek
- Department of Nuclear Medicine, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Gareth Ayre
- Department of Radiation Oncology, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Maria Aparicio
- Department of Radiation Oncology, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Lovedeep Gondara
- Cancer Surveillance and Outcomes, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Caroline Speers
- Cancer Surveillance and Outcomes, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Alan Nichol
- Department of Radiation Oncology, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada.
- Cancer Surveillance and Outcomes, BC Cancer, Vancouver Centre, Vancouver, British Columbia, Canada.
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