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Wu XY, Chen M, Cao L, Li M, Chen JY. Proton Therapy in Breast Cancer: A Review of Potential Approaches for Patient Selection. Technol Cancer Res Treat 2024; 23:15330338241234788. [PMID: 38389426 PMCID: PMC10894553 DOI: 10.1177/15330338241234788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/25/2023] [Accepted: 02/06/2024] [Indexed: 02/24/2024] Open
Abstract
Proton radiotherapy may be a compelling technical option for the treatment of breast cancer due to its unique physical property known as the "Bragg peak." This feature offers distinct advantages, promising superior dose conformity within the tumor area and reduced radiation exposure to surrounding healthy tissues, enhancing the potential for better treatment outcomes. However, proton therapy is accompanied by inherent challenges, primarily higher costs and limited accessibility when compared to well-developed photon irradiation. Thus, in clinical practice, it is important for radiation oncologists to carefully select patients before recommendation of proton therapy to ensure the transformation of dosimetric benefits into tangible clinical benefits. Yet, the optimal indications for proton therapy in breast cancer patients remain uncertain. While there is no widely recognized methodology for patient selection, numerous attempts have been made in this direction. In this review, we intended to present an inspiring summarization and discussion about the current practices and exploration on the approaches of this treatment decision-making process in terms of treatment-related side-effects, tumor control, and cost-efficiency, including the normal tissue complication probability (NTCP) model, the tumor control probability (TCP) model, genomic biomarkers, cost-effectiveness analyses (CEAs), and so on. Additionally, we conducted an evaluation of the eligibility criteria in ongoing randomized controlled trials and analyzed their reference value in patient selection. We evaluated the pros and cons of various potential patient selection approaches and proposed possible directions for further optimization and exploration. In summary, while proton therapy holds significant promise in breast cancer treatment, its integration into clinical practice calls for a thoughtful, evidence-driven strategy. By continuously refining the patient selection criteria, we can harness the full potential of proton radiotherapy while ensuring maximum benefit for breast cancer patients.
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Affiliation(s)
- Xiao-Yu Wu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Mei Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Lu Cao
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Min Li
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jia-Yi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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Yang Y, Gergelis KR, Shen J, Afzal A, Mullikin TC, Gao RW, Aziz K, Shumway DA, Corbin KS, Liu W, Mutter RW. Study of linear energy transfer effect on rib fracture in breast patients receiving pencil-beamscanning proton therapy. ArXiv 2023:arXiv:2310.20527v1. [PMID: 37961731 PMCID: PMC10635309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Purpose To study the effect of proton linear energy transfer (LET) on rib fracture in breast cancer patients treated with pencil-beam scanning proton therapy (PBS) using a novel tool of dose-LET volume histogram (DLVH). Methods From a prospective registry of patients treated with post-mastectomy proton therapy to the chest wall and regional lymph nodes for breast cancer between 2015 and 2020, we retrospectively identified rib fracture cases detected after completing treatment. Contemporaneously treated control patients that did not develop rib fracture were matched to patients 2:1 considering prescription dose, boost location, reconstruction status, laterality, chest wall thickness, and treatment year.The DLVH index, V(d, l), defined as volume(V) of the structure with at least dose(d) and LET(l), was calculated. DLVH plots between the fracture and control group were compared. Conditional logistic regression (CLR) model was used to establish the relation of V(d, l) and the observed fracture at each combination of d and l. The p-value derived from CLR model shows the statistical difference between fracture patients and the matched control group. Using the 2D p-value map derived from CLR model, the DLVH features associated with the patient outcomes were extracted. Results Seven rib fracture patients were identified, and fourteen matched patients were selected for the control group. The median time from the completion of proton therapy to rib fracture diagnosis was 12 months (range 5 to 14 months). Two patients had grade 2 symptomatic rib fracture while the remaining 5 were grade 1 incidentally detected on imaging. The derived p-value map demonstrated larger V(0-36Gy[RBE], 4.0-5.0 keV/μm) in patients experiencing fracture (p<0.1). For example, the p value for V(30 Gy[RBE], 4.0 keV/um) was 0.069. Conclusions In breast cancer patients receiving PBS, a larger volume of chest wall receiving moderate dose and high LET may result in increased risk of rib fracture.
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Affiliation(s)
- Yunze Yang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Kimberly R Gergelis
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Radiation Oncology, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Arslan Afzal
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Trey C Mullikin
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC 27710
| | - Robert W Gao
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Khaled Aziz
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Kimberly S Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Pharmacology, Mayo Clinic, Rochester, MN 55905, USA
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Alterio D, La Rocca E, Volpe S, Camarda AM, Casbarra A, Russell-Edu W, Zerella MA, Orecchia R, Galimberti V, Veronesi P, Leonardi MC, Jereczek-Fossa BA. Hypofractionated proton therapy in breast cancer: where are we? A critical review of the literature. Breast Cancer Res Treat 2022; 192:249-263. [PMID: 35025004 DOI: 10.1007/s10549-022-06516-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 01/03/2022] [Indexed: 02/06/2023]
Abstract
PURPOSE To critically review available literature on hypofractionated (≥ 3 Gy/fraction) proton therapy (PT) for breast cancer (BCa). METHODS A systematic screening of the literature was performed in April 2021 in compliance with the preferred reporting items for systematic reviews and meta-analyses recommendations. All full-text publication written in English were considered eligible. Acute and late toxicities, oncological outcomes and dosimetric features were considered for the analysis. RESULTS Twelve publications met the inclusion criteria; all studies but one focused on accelerated partial breast irradiation (APBI). Eleven works considered post-operative patients, one referred to ABPI as a curative-intent modality. The dosimetric profile of PT compared favorably with both photon-based 3D conformal and intensity-modulated techniques, while a more extended follow-up is warranted to fully assess both the long-term toxicities and the non-inferiority of oncological outcomes. CONCLUSION Our work shows that results on PT for BCa are currently only available for APBI applications, with dosimetric analyses demonstrating a clear advantage over both 3D conformal and intensity modulated X-rays techniques, especially when ≥ 2 treatment fields were used. However, further evidence is needed to define whether such theoretical benefit translates into clinical improvements, especially in the long-term.
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Affiliation(s)
- Daniela Alterio
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCSS, Milan, Italy
| | - Eliana La Rocca
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCSS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Stefania Volpe
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCSS, Milan, Italy. .,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - Anna Maria Camarda
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCSS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Alessia Casbarra
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCSS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | | | - Maria Alessia Zerella
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCSS, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology (IEO) IRCSS, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology (IEO) IRCSS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology (IEO) IRCSS, Milan, Italy
| | | | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology (IEO) IRCSS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Musielak M, Suchorska WM, Fundowicz M, Milecki P, Malicki J. Future Perspectives of Proton Therapy in Minimizing the Toxicity of Breast Cancer Radiotherapy. J Pers Med 2021; 11:jpm11050410. [PMID: 34068305 PMCID: PMC8153289 DOI: 10.3390/jpm11050410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 11/16/2022] Open
Abstract
The toxicity of radiotherapy is a key issue when analyzing the eligibility criteria for patients with breast cancer. In order to obtain better results, proton therapy is proposed because of the more favorable distribution of the dose in the patient’s body compared with photon radiotherapy. Scientific groups have conducted extensive research into the improved efficacy and lower toxicity of proton therapy for breast cancer. Unfortunately, there is no complete insight into the potential reasons and prospects for avoiding undesirable results. Cardiotoxicity is considered challenging; however, researchers have not presented any realistic prospects for preventing them. We compared the clinical evidence collected over the last 20 years, providing the rationale for the consideration of proton therapy as an effective solution to reduce cardiotoxicity. We analyzed the parameters of the dose distribution (mean dose, Dmax, V5, and V20) in organs at risk, such as the heart, blood vessels, and lungs, using the following two irradiation techniques: whole breast irradiation and accelerated partial breast irradiation. Moreover, we presented the possible causes of side effects, taking into account biological and technical issues. Finally, we collected potential improvements in higher quality predictions of toxic cardiac effects, like biomarkers, and model-based approaches to give the full background of this complex issue.
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Affiliation(s)
- Marika Musielak
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiobiology Laboratory, Department of Medical Physics, 61-866 Poznan, Poland
- Correspondence: ; Tel.: +48-505372290
| | - Wiktoria M. Suchorska
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiobiology Laboratory, Department of Medical Physics, 61-866 Poznan, Poland
| | | | - Piotr Milecki
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiotherapy Ward I, 61-866 Poznan, Poland;
| | - Julian Malicki
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Medical Physics Department, 61-866 Poznan, Poland
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Parham MD, Ahmad S, Jin H. Dosimetric Effect of Biozorb Markers for Accelerated Partial Breast Irradiation in Proton Therapy. Int J Part Ther 2021; 7:19-28. [PMID: 33829070 PMCID: PMC8019574 DOI: 10.14338/ijpt-20-00077.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/22/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose To investigate dosimetric implications of biodegradable Biozorb (BZ) markers for proton accelerated partial breast irradiation (APBI) plans. Materials and Methods Six different BZs were placed within in-house breast phantoms to acquire computed tomography (CT) images. A contour correction method with proper mass density overriding for BZ titanium clip and surrounding tissue was applied to minimize inaccuracies found in the CT images in the RayStation planning system. Each breast phantom was irradiated by a monoenergetic proton beam (103.23 MeV and 8×8 cm2) using a pencil-beam scanning proton therapy system. For a range perturbation study, doses were measured at 5 depths below the breast phantoms by using an ionization chamber and compared to the RayStation calculations with 3 scenarios for the clip density: the density correction method (S1: 1.6 g/cm3), raw CT (S2), and titanium density (S3: 4.54 g/cm3). For the local dose perturbation study, the radiographic EDR2 film was placed at 0 and 2 cm below the phantoms and compared to the RayStation calculations. Clinical effects of the perturbations were retrospectively examined with 10 APBI plans for the 3 scenarios (approved by our institutional review board). Results In the range perturbation study, the S1 simulation showed a good agreement with the chamber measurements, while excess pullbacks of 1∼2 mm were found in the S2 and S3 simulations. The film study showed local dose shadowing and perturbation by the clips that RayStation could not predict. In the plan study, no significant differences in the plan quality were found among the 3 scenarios. However, substantial range pullbacks were observed for S3. Conclusion The density correction method could minimize the dose and range difference between measurement and RayStation prediction. It should be avoided to simply override the known physical density of the BZ clips for treatment planning owing to overestimation of the range pullback.
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Affiliation(s)
| | - Salahuddin Ahmad
- Department of Radiation Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Hosang Jin
- Department of Radiation Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Mutter RW, Jethwa KR, Gonuguntla K, Remmes NB, Whitaker TJ, Hieken TJ, Ruddy KJ, McGee LA, Corbin KS, Park SS. 3 fraction pencil-beam scanning proton accelerated partial breast irradiation: early provider and patient reported outcomes of a novel regimen. Radiat Oncol 2019; 14:211. [PMID: 31752934 PMCID: PMC6873533 DOI: 10.1186/s13014-019-1417-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 11/07/2019] [Indexed: 12/19/2022] Open
Abstract
Background and purpose To report dosimetry and early adverse effects, aesthetic, and patient-reported outcomes of a prospective study of 3-fraction pencil-beam scanning (PBS) proton accelerated partial irradiation (APBI). Materials and methods Eligibility included women age ≥ 50 years with estrogen receptor positive (ER+), sentinel lymph node negative invasive or in-situ breast cancer measuring ≤2.5 cm. The prescription was 21.9 Gy (RBE 1.1) in 3 daily fractions to the post-operative tumor bed with a 1 cm expansion. Toxicities were collected using Common Terminology Criteria for Adverse Events (CTCAE) version 4.0, 10-point Linear Analog Scale Assessment, Patient-Reported Outcomes Version of the CTCAE, and the Harvard Breast Cosmesis Scale. Results Seventy-six women were treated between 2015 and 2017. The median breast volume receiving 50% of prescription or more was 28%. Median mean heart, mean ipsilateral lung, and maximum skin dose were 0 Gy, 0.1 Gy, and 20.6 Gy, respectively. With a median follow-up of 12 months, no treatment-related toxicity grade ≥ 2 has been observed. Most common grade 1 adverse events were dermatitis (68%) and skin hyperpigmentation (18%). At 12 months, the only persistent toxicities were one patient with grade 1 breast edema and one patient with a grade 1 seroma. 90% of patients reported quality of life as ≥7 out of 10 (0 indicating “as bad as it can be” and 10 indicating “as good as it can be”) and 98% of patients reported excellent or good cosmesis. Conclusion 3-fraction PBS proton APBI is well tolerated with low rates of physician and patient reported early adverse effects. Follow-up is ongoing to assess late toxicities and disease control outcomes. Further investigation of this novel adjuvant treatment strategy is warranted.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Karthik Gonuguntla
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Nicholas B Remmes
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Thomas J Whitaker
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Kimberly S Corbin
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
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Korevaar EW, Habraken SJM, Scandurra D, Kierkels RGJ, Unipan M, Eenink MGC, Steenbakkers RJHM, Peeters SG, Zindler JD, Hoogeman M, Langendijk JA. Practical robustness evaluation in radiotherapy - A photon and proton-proof alternative to PTV-based plan evaluation. Radiother Oncol 2019; 141:267-274. [PMID: 31492443 DOI: 10.1016/j.radonc.2019.08.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/23/2019] [Accepted: 08/10/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE A planning target volume (PTV) in photon treatments aims to ensure that the clinical target volume (CTV) receives adequate dose despite treatment uncertainties. The underlying static dose cloud approximation (the assumption that the dose distribution is invariant to errors) is problematic in intensity modulated proton treatments where range errors should be taken into account as well. The purpose of this work is to introduce a robustness evaluation method that is applicable to photon and proton treatments and is consistent with (historic) PTV-based treatment plan evaluations. MATERIALS AND METHODS The limitation of the static dose cloud approximation was solved in a multi-scenario simulation by explicitly calculating doses for various treatment scenarios that describe possible errors in the treatment course. Setup errors were the same as the CTV-PTV margin and the underlying theory of 3D probability density distributions was extended to 4D to include range errors, maintaining a 90% confidence level. Scenario dose distributions were reduced to voxel-wise minimum and maximum dose distributions; the first to evaluate CTV coverage and the second for hot spots. Acceptance criteria for CTV D98 and D2 were calibrated against PTV-based criteria from historic photon treatment plans. RESULTS CTV D98 in worst case scenario dose and voxel-wise minimum dose showed a very strong correlation with scenario average D98 (R2 > 0.99). The voxel-wise minimum dose visualised CTV dose conformity and coverage in 3D in agreement with PTV-based evaluation in photon therapy. Criteria for CTV D98 and D2 of the voxel-wise minimum and maximum dose showed very strong correlations to PTV D98 and D2 (R2 > 0.99) and on average needed corrections of -0.9% and +2.3%, respectively. CONCLUSIONS A practical approach to robustness evaluation was provided and clinically implemented for PTV-less photon and proton treatment planning, consistent with PTV evaluations but without its static dose cloud approximation.
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Affiliation(s)
- Erik W Korevaar
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands.
| | - Steven J M Habraken
- Holland Proton Therapy Center, Delft, The Netherlands; Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Daniel Scandurra
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Roel G J Kierkels
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Mirko Unipan
- Proton Therapy Centre South-East Netherlands (ZON-PTC), Maastricht, The Netherlands
| | | | - Roel J H M Steenbakkers
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Stephanie G Peeters
- Proton Therapy Centre South-East Netherlands (ZON-PTC), Maastricht, The Netherlands
| | - Jaap D Zindler
- Holland Proton Therapy Center, Delft, The Netherlands; Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Mischa Hoogeman
- Holland Proton Therapy Center, Delft, The Netherlands; Department of Radiation Oncology, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, The Netherlands
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Underwood TSA, Grassberger C, Bass R, MacDonald SM, Meyersohn NM, Yeap BY, Jimenez RB, Paganetti H. Asymptomatic Late-phase Radiographic Changes Among Chest-Wall Patients Are Associated With a Proton RBE Exceeding 1.1. Int J Radiat Oncol Biol Phys 2018; 101:809-819. [PMID: 29976493 DOI: 10.1016/j.ijrobp.2018.03.037] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 02/13/2018] [Accepted: 03/26/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Clinical practice assumes a fixed proton relative biological effectiveness (RBE) of 1.1, but in vitro experiments demonstrate higher RBEs at the distal edge of the proton spread-out Bragg peak, that is, in a region that falls within the lung for chest-wall patients. We performed retrospective qualitative and quantitative analyses of lung-density changes-indicative of asymptomatic fibrosis-for chest-wall patients treated with protons or photons. Our null hypothesis was that, assuming a fixed RBE of 1.1, these changes would be the same for the 2 cohorts, supporting current RBE practice. Our alternative hypothesis was that radiographic abnormalities would be greater for the proton cohort, suggesting an RBE > 1.1. METHODS AND MATERIALS We analyzed follow-up computed tomography (CT) scans for 20 proton and photon patients. All were prescribed 50.4 Gy (RBE) in 28 fractions, assuming a fixed RBE of 1.1 for protons and 1 for photons. Deformable registrations enabled us to calculate density changes in the normal lung, specifically (1) median Hounsfield unit (HU) values among posttreatment CT scans and (2) changes in median HU values between pretreatment and posttreatment CT scans, both as a function of grays (RBE). In addition, qualitative abnormality grading was performed by a radiologist. RESULTS Proton patients exhibited higher values of HU/Gy (RBE) (endpoint 1) and ΔHU/Gy (RBE) (endpoint 2): P = .049 and P = .00019, respectively, were obtained (likelihood ratio tests of full linear mixed-effects models against models without "modality"). Furthermore, qualitative radiologic scoring indicated a significant difference between the cohorts (Wilcoxon P = .018; median score, 3 of 9 for protons and 1.5 of 9 for photons). CONCLUSIONS Our data support the hypothesis that the proton RBE for lung-density changes exceeds 1.1. This RBE elevation could be attributable to (1) the late, normal tissue endpoint that we consider or (2) end-of-range proton linear energy transfer elevation-or a combination of the two. Regardless, our results suggest that variations in proton RBE prove important in vivo as well as in vitro.
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Affiliation(s)
- Tracy S A Underwood
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rhedise Bass
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nandini M Meyersohn
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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9
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Ovalle V, Strom EA, Shaitelman S, Hoffman K, Amos R, Perkins G, Tereffe W, Smith BD, Stauder M, Woodward W. Proton Partial Breast Irradiation: Detailed Description of Acute Clinico-Radiologic Effects. Cancers (Basel) 2018; 10:E111. [PMID: 29642467 DOI: 10.3390/cancers10040111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/26/2018] [Accepted: 04/04/2018] [Indexed: 12/04/2022] Open
Abstract
Introduction: Accelerated partial breast irradiation (APBI) with protons results in a very different acute effect profile than standard whole breast irradiation. We reviewed our initial experience with proton APBI and felt that a detailed description of these effects were needed to permit a common tool to compare experience with this developing technology. Methods: Sixty sequential patients treated with proton APBI on a prospective protocol were evaluated and 43 patients with a minimum six-month follow-up underwent detailed photographic and radiologic analysis. The tumorectomy cavity plus an additional 1.5 cm clinical target volume (CTV) was treated with two or three passively-scattered proton beams to a dose of 34 Gy in 10 fractions in one week. Photographs were taken at the end of radiation, at two weeks, six weeks, and every six months thereafter. Mammography was obtained at six months after radiation and annually thereafter. All visual changes were categorized using the smallest meaningful gradations in findings and are demonstrated herein. All treatment-related mammographic findings are reported. Findings: Visual and mammographic findings showed a clear time-dependent relationship and significant variation between individuals. Peak skin reaction occurred at two to six weeks after completion of therapy. At two weeks most patients had either no visible effects and patchy erythema involving <50% of the treated skin (60%). At six weeks most patients had either patchy erythema involving <50% of the overlying skin (33%) or patchy erythema involving >50% of the treated skin (28%). Only one patient developed any moist desquamation. At six months most patients had no visible skin changes (57%) or a small, circular area of mild hyperpigmentation (33%). Mammographic changes seen at six months were regional skin thickening (40%), residual seroma (14%), localized retraction (26%), and fat necrosis (2%). A subcategorized variant on the CTCAE 4.0 was developed to foster granular recording of these findings.
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Yu J, Park SS, Herman MG, Langen K, Mehta M, Feigenberg SJ. Free Breathing versus Breath-Hold Scanning Beam Proton Therapy and Cardiac Sparing in Breast Cancer. Int J Part Ther 2017; 3:407-413. [PMID: 31772990 DOI: 10.14338/ijpt-16-00021.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/16/2016] [Indexed: 12/25/2022] Open
Abstract
Purpose To assess dose errors caused by the interplay effects of free-breathing (FB) motion and to assess the value of breath-hold (BH) in terms of cardiac dose reduction for scanning beam proton therapy (SBPT). Materials and Methods Three patients with left-sided breast cancer previously treated with photon therapy were included in this dosimetric study: 2 following breast-conserving surgery with 2 hypothetical target volumes (whole breast alone and whole breast plus regional nodes, including supraclavicular, axillary, and internal mammary lymph nodes); and 1 postmastectomy, with the target volume including the chest wall plus regional nodes. SBPT plans were generated with various beam angles that ranged between 2 tangential directions. For treatment with FB, nominal dose and dose with interplay effects considered were calculated based on FB 4-dimensional computed tomography scans. SBPT plans on the BH computed tomography were also calculated for one of the patients, who was selected to be treated with photon therapy with BH. Results Dosimetric differences between nominal and interplay dose were small (average target mean dose, -0.06 Gy; range, -0.23 to 0.06 Gy; average heart mean dose, 0.001 Gy; range, -0.12 to 0.05 Gy). The largest dose deviations occurred in plans calculated with tangential beam arrangements; the smallest was noted with the en face beam. The average value of the mean heart dose with FB was <1 Gy. For the selected patient, the mean heart doses were 0.5 and 0.2 Gy for FB and BH, respectively. Conclusion Dose deviations caused by the interplay effects of respiratory motion during FB do not have a significant impact in SBPT with en face beam arrangement. BH does not significantly reduce cardiac dose. SBPT delivery is feasible with FB and can provide optimal target coverage and maximal sparing of the cardiopulmonary system, which can translate into improved clinical outcomes and a decrease in treatment-related morbidity in left-sided breast cancer patients or those who require internal mammary node coverage.
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Affiliation(s)
- Jen Yu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Michael G Herman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Katja Langen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Minesh Mehta
- Radiation Oncology Department, Baptist Hospital South Florida, Miami, FL, USA
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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11
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Yashar C, Attai D, Butler E, Einck J, Finkelstein S, Han B, Hong R, Komarnicky L, Lyden M, Mantz C, Morcovescu S, Nigh S, Perry K, Pollock J, Reiff J, Scanderbeg D, Snyder M, Kuske R. Strut-based accelerated partial breast irradiation: Report of treatment results for 250 consecutive patients at 5 years from a multicenter retrospective study. Brachytherapy 2016; 15:780-7. [DOI: 10.1016/j.brachy.2016.07.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 12/13/2022]
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12
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Chand-Fouché ME, Lam Cham Kee D, Gautier M, Hannoun-Levi JM. Technique d’irradiation partielle du sein : radiothérapie externe et curiethérapie. Cancer Radiother 2016; 20:587-94. [DOI: 10.1016/j.canrad.2016.07.087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/12/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
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13
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Mondal D, Sharma DN. External beam radiation techniques for breast cancer in the new millennium: New challenging perspectives. J Egypt Natl Canc Inst 2016; 28:211-218. [PMID: 27595191 DOI: 10.1016/j.jnci.2016.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/26/2016] [Accepted: 08/01/2016] [Indexed: 11/17/2022] Open
Abstract
Radiation therapy in breast cancer has evolved dramatically over the past century. It has traveled a long path touching different milestones and taking unprecedented turns. At the end, a fine tune of clinical understanding, skill, technological advancement and translation of radiobiological understanding to clinical outcome has taken place. What all these have given is better survival with quality survivorship. It is thus prudent to understand breast irradiation in a new perspective suitable for the current millennium.
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Affiliation(s)
- Dodul Mondal
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Daya Nand Sharma
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi 110029, India
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14
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Hernandez M, Zhang R, Sanders M, Newhauser W. A treatment planning comparison of volumetric modulated arc therapy and proton therapy for a sample of breast cancer patients treated with post-mastectomy radiotherapy. ACTA ACUST UNITED AC 2016; 1. [PMID: 29104948 DOI: 10.14319/jpt.11.9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Post-mastectomy radiotherapy (PMRT) has been shown to improve disease-free survival and overall survival for locally advanced breast cancer. However, long term survivors may develop life threatening acute and chronic treatment-related toxicities after radiotherapy, like cardiac toxicity and second cancers. The more advanced techniques like volumetric arc therapy (VMAT), and proton therapy have the potential to improve treatment outcome by constraining doses to radiosensitive organs, but evidence from outcome study will not be available until years or decades later. Furthermore, the literature is largely incomplete regarding systematic comparison of potential benefits of advanced technologies for PMRT. The purpose of this study was to compare proton therapy, both passively scattered (PSPT) and intensity modulated (IMPT), to VMAT and develop an evidence-based rationale for selecting a treatment modality for left sided post-mastectomy radiotherapy (PMRT) patients. Eight left-sided PMRT patients previously treated with VMAT were included in this study. Planning target volumes (PTV) included the chest wall and regional lymph nodes. PSPT and IMPT plans were created using a commercial proton treatment planning system. The resulting plans were compared to the corresponding VMAT on the basis of dosimetric and radiobiological endpoints. The uncertainties in risk from proton range, set-up errors, and dose-response models were also evaluated. All modalities produced clinically acceptable treatment plans with nearly 100% tumor control probability. Both proton techniques provided significantly lower normal tissue complication probability values for the heart (p < 0.02) and lung (p < 0.001). Patient-averaged second cancer risk for the contralateral breast and lungs were also significantly lower (p < 0.001) with protons compared to VMAT. The findings of this study were upheld by the uncertainty analysis. All three techniques provided acceptable PMRT treatment plans. Proton therapy showed significant advantages in terms of predicted normal tissue sparing compared to VMAT, taking into account possible uncertainties.
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Affiliation(s)
- Margaret Hernandez
- Department of Physics, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, USA
| | - Rui Zhang
- Department of Physics, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, USA.,Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Mary Sanders
- Department of Radiation Oncology, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, USA
| | - Wayne Newhauser
- Department of Physics, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, USA.,Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, USA
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15
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Mast ME, Vredeveld EJ, Credoe HM, van Egmond J, Heijenbrok MW, Hug EB, Kalk P, van Kempen-Harteveld LM, Korevaar EW, van der Laan HP, Langendijk JA, Rozema HJ, Petoukhova AL, Schippers JM, Struikmans H, Maduro JH. Whole breast proton irradiation for maximal reduction of heart dose in breast cancer patients. Breast Cancer Res Treat 2014; 148:33-9. [PMID: 25266130 DOI: 10.1007/s10549-014-3149-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 09/20/2014] [Indexed: 02/01/2023]
Abstract
Purpose In left-sided breast cancer radiotherapy, tangential intensity modulated radiotherapy combined with breath-hold enables a dose reduction to the heart and left anterior descending (LAD) coronary artery. Aim of this study was to investigate the added value of intensity modulated proton therapy (IMPT) with regard to decreasing the radiation dose to these structures. Methods In this comparative planning study, four treatment plans were generated in 20 patients: an IMPT plan and a tangential IMRT plan, both with breath-hold and free-breathing. At least 97 % of the target volume had to be covered by at least 95 % of the prescribed dose in all cases. Specifically with respect to the heart, the LAD, and the target volumes, we analyzed the maximum doses, the mean doses, and the volumes receiving 5–30 Gy. Results As compared to IMRT, IMPT resulted in significant dose reductions to the heart and LAD-region even without breath-hold. In the majority of the IMPT cases, a reduction to almost zero to the heart and LAD-region was obtained. IMPT treatment plans yielded the lowest dose to the lungs. Conclusions With IMPT the dose to the heart and LAD-region could be significantly decreased compared to tangential IMRT with breath-hold. The clinical relevance should be assessed individually based on the baseline risk of cardiac complications in combination with the dose to organs at risk. However, as IMPT for breast cancer is currently not widely available, IMPT should be reserved for patients remaining at high risk for major coronary events.
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Abstract
Densely ionizing radiation has always been a main topic in radiobiology. In fact, α-particles and neutrons are sources of radiation exposure for the general population and workers in nuclear power plants. More recently, high-energy protons and heavy ions attracted a large interest for two applications: hadrontherapy in oncology and space radiation protection in manned space missions. For many years, studies concentrated on measurements of the relative biological effectiveness (RBE) of the energetic particles for different end points, especially cell killing (for radiotherapy) and carcinogenesis (for late effects). Although more recently, it has been shown that densely ionizing radiation elicits signalling pathways quite distinct from those involved in the cell and tissue response to photons. The response of the microenvironment to charged particles is therefore under scrutiny, and both the damage in the target and non-target tissues are relevant. The role of individual susceptibility in therapy and risk is obviously a major topic in radiation research in general, and for ion radiobiology as well. Particle radiobiology is therefore now entering into a new phase, where beyond RBE, the tissue response is considered. These results may open new applications for both cancer therapy and protection in deep space.
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Affiliation(s)
- M Durante
- GSI Helmholtz Center for Heavy Ion Research, Biophysics Department, Darmstadt, Germany
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17
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Galland-Girodet S, Pashtan I, MacDonald SM, Ancukiewicz M, Hirsch AE, Kachnic LA, Specht M, Gadd M, Smith BL, Powell SN, Recht A, Taghian AG. Long-term cosmetic outcomes and toxicities of proton beam therapy compared with photon-based 3-dimensional conformal accelerated partial-breast irradiation: a phase 1 trial. Int J Radiat Oncol Biol Phys 2014; 90:493-500. [PMID: 24880212 DOI: 10.1016/j.ijrobp.2014.04.008] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/04/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To present long-term outcomes of a prospective feasibility trial using either protons or 3-dimensional conformal photon-based (accelerated partial-breast irradiation [APBI]) techniques. METHODS AND MATERIALS From October 2003 to April 2006, 98 evaluable patients with stage I breast cancer were treated with APBI (32 Gy in 8 fractions given twice daily) on a prospective clinical trial: 19 with proton beam therapy (PBT) and 79 with photons or mixed photons/electrons. Median follow-up was 82.5 months (range, 2-104 months). Toxicity and patient satisfaction evaluations were performed at each visit. RESULTS At 7 years, the physician rating of overall cosmesis was good or excellent for 62% of PBT patients, compared with 94% for photon patients (P=.03). Skin toxicities were more common for the PBT group: telangiectasia, 69% and 16% (P=.0013); pigmentation changes, 54% and 22% (P=.02); and other late skin toxicities, 62% and 18% (P=.029) for PBT and photons, respectively. There were no significant differences between the groups in the incidences of breast pain, edema, fibrosis, fat necrosis, skin desquamation, and rib pain or fracture. Patient-reported cosmetic outcomes at 7 years were good or excellent for 92% and 96% of PBT and photon patients, respectively (P=.95). Overall patient satisfaction was 93% for the entire cohort. The 7-year local failure rate for all patients was 6%, with 3 local recurrences in the PBT group (7-year rate, 11%) and 2 in photon-treated patients (4%) (P=.22). CONCLUSIONS Local failure rates of 3-dimensional APBI and PBT were similar in this study. However, PBT, as delivered in this study, led to higher rates of long-term telangiectasia, skin color changes, and skin toxicities. We recommend the use of multiple fields and treatment of all fields per treatment session or the use of scanning techniques to minimize skin toxicity.
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Affiliation(s)
| | - Itai Pashtan
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Marek Ancukiewicz
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ariel E Hirsch
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Lisa A Kachnic
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Michelle Specht
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Michele Gadd
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Barbara L Smith
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Simon N Powell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Abram Recht
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
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18
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Akamatsu H, Karasawa K, Omatsu T, Isobe Y, Ogata R, Koba Y. First experience of carbon-ion radiotherapy for early breast cancer. Jpn J Radiol 2014; 32:288-95. [PMID: 24615166 DOI: 10.1007/s11604-014-0300-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 02/19/2014] [Indexed: 11/26/2022]
Abstract
Breast cancer is increasingly being detected at earlier stages, and partial breast irradiation for patients with low-risk-group tumor has come to be applied in the US and Europe as an alternative to whole-breast irradiation. Based on those experiences, some institutes have tried using particle beams for partial breast irradiation for postoperative or radical intent for early breast cancer, but technical difficulties have hindered its progress. The National Institute of Radiological Sciences has been preparing for carbon-ion radiotherapy (C-ion RT) with radical intent for stage I breast cancer since 2011, and we carried out the first treatment in April 2013. In this case report, we explain our first experience of C-ion RT as a treatment procedure for breast tumor and present the radiation techniques and preliminary treatment results as a reference for other institutes trying to perform the same kind of treatment.
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Affiliation(s)
- Hiroko Akamatsu
- Research Center Hospital for Charged Particle Therapy, National Institute of Radiological Sciences, 4-9-1 Anagawa, Inage-ku, Chiba, Chiba, 263-8555, Japan,
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