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Nichol A, Wade L, Gondara L, Musoke R, Chang JS, Swift CL, Chng N, Narinesingh D, Speers C, Lohrisch C. A Matched Case-Control Study of the Relationship Between Radiation Dose to the Internal Mammary Lymph Nodes and Clinical Outcomes in Patients With and Without Internal Mammary Lymph Node Relapses. Int J Radiat Oncol Biol Phys 2025:S0360-3016(25)00144-0. [PMID: 39986486 DOI: 10.1016/j.ijrobp.2025.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 01/10/2025] [Accepted: 02/04/2025] [Indexed: 02/24/2025]
Abstract
PURPOSE The Early Breast Cancer Trialists' Collaborative Group's 2023 meta-analysis of radiation therapy to regional nodes in early breast cancer demonstrated a significant improvement in overall survival (OS) without an associated improvement in locoregional recurrence in the trials comparing internal mammary node (IMN) irradiation versus none. We aimed to study cases with IMN relapse (IMNR) and controls without IMNR to examine the link between IMNR and OS. METHODS AND MATERIALS Patients treated curatively between 2005 and 2014, who subsequently developed IMNR, were identified in a population-based database. The IMNR cases were matched 1:2 to controls without IMNR using patient and tumor characteristics. The internal mammary vessels in the first 3 intercostal spaces were outlined on planning computed tomography scans as the IMN clinical target volume, and the mean equivalent doses in 2-Gy fractions to the IMNs were calculated. Multivariable Fine and Gray competing-risk regression and Cox regression were used to evaluate the effect of the baseline patient, tumor, and treatment variables, including therapeutic IMN irradiation with ≥40 Gy on IMNR and OS. RESULTS Seventy cases were matched with 140 controls. Median follow-up was 9.1 years, median tumor size was 25 mm, and N-stages were: 37% N0, 33% N1, and 30% N2-3. The medians of the IMN doses were 4.1 Gy for cases and 13.7 Gy for controls (P < .001). On multivariable analysis, worse IMNR was associated with mastectomy (hazard ratio [HR], 2.11; P = .02), and better IMNR was associated with therapeutic IMN irradiation (HR, 0.36; P = .009); worse OS was associated with larger tumor size (HR, 1.02; P = .006), ≥10 positive axillary nodes (HR, 3.15; P = .04), and triple-negative subtype (HR, 2.92; P = .03), and better OS was associated with therapeutic IMN irradiation (HR, 0.49; P = .02). CONCLUSIONS We demonstrated that therapeutic IMN irradiation with ≥40 Gy was associated with both a lower risk of IMNR and improved OS.
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Affiliation(s)
- Alan Nichol
- BC Cancer - Vancouver, British Columbia, Canada; Division of Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Louise Wade
- BC Cancer - Vancouver, British Columbia, Canada
| | | | | | - Jee Suk Chang
- BC Cancer - Vancouver, British Columbia, Canada; Yonsei University College of Medicine, Seoul, Korea
| | | | | | - Dylan Narinesingh
- BC Cancer - Vancouver, British Columbia, Canada; Division of Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Caroline Lohrisch
- BC Cancer - Vancouver, British Columbia, Canada; Division of Medical Oncology, University of British Columbia, Vancouver, British Columbia, Canada
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Recht A. Internal Mammary Node Irradiation Debate: Case Closed? Not Yet, and Maybe Never. J Clin Oncol 2024; 42:1871-1874. [PMID: 38498804 DOI: 10.1200/jco.23.02480] [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: 11/16/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/20/2024] Open
Abstract
The IMN debate is still open and may never be closed for reasons outlined in this Comments and Controversies piece.
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Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Internal mammary node irradiation improves 8-year survival in breast cancer patients: results from a retrospective cohort study in real-world setting. Breast Cancer 2019; 27:252-260. [DOI: 10.1007/s12282-019-01015-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/03/2019] [Indexed: 12/17/2022]
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Yee C, Wang K, Asthana R, Drost L, Lam H, Lee J, Vesprini D, Leung E, DeAngelis C, Chow E. Radiation-induced Skin Toxicity in Breast Cancer Patients: A Systematic Review of Randomized Trials. Clin Breast Cancer 2018; 18:e825-e840. [DOI: 10.1016/j.clbc.2018.06.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/05/2018] [Accepted: 06/29/2018] [Indexed: 11/25/2022]
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Dess RT, Liss AL, Griffith KA, Marsh RB, Moran JM, Mayo C, Koelling TM, Jagsi R, Hayman JA, Pierce LJ. Ischemic Cardiac Events Following Treatment of the Internal Mammary Nodal Region Using Contemporary Radiation Planning Techniques. Int J Radiat Oncol Biol Phys 2017; 99:1146-1153. [PMID: 28864405 DOI: 10.1016/j.ijrobp.2017.06.2459] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 05/08/2017] [Accepted: 06/22/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Regional nodal irradiation, including radiation therapy (RT) to the internal mammary node (IMN) region, improves oncologic outcomes in patients with node-positive breast cancer. Concern remains, however, given the proximity of the IMNs to the heart and the association between cardiac RT exposure and toxicity. The objective of the study was to evaluate rates of ischemic cardiac events (ICEs) and associated risk with treatment of the IMN region. METHODS AND MATERIALS The cardiac outcomes of 2126 patients treated with adjuvant breast RT or breast and nodal RT from 1984 to 2007 at a single institution were reviewed. The primary endpoint was an ICE following RT initiation. The association between IMN RT and ICEs was assessed using Cox proportional hazards models. Treatment with both IMN RT and 3-dimensional (3D) conformal radiation therapy (CRT) began in 1997; therefore, subset analyses of patients with only 3D CRT were performed to minimize bias associated with improved treatment technique. RESULTS The median follow-up period was 9.3 years. An ICE occurred in 87 patients (4.1%). No increased 10-year rate of ICEs was observed with IMN RT compared with no IMN RT in the total cohort (3.2% [95% confidence interval (CI), 2.4%-4.3%] vs 3.4% [95% CI, 1.5%-7.5%]; hazard ratio [HR], 0.88; P=.73). Similarly, no statistically significant difference was noted in the 3D CRT-planned, left-sided disease subset (5.1% [95% CI, 1.8%-14.1%] vs 4.0% [95% CI, 2.0%-8.0%]; HR, 1.18, P=.76). On multivariate analysis, adjusting for cardiac risk factor imbalances, no significantly increased hazard was noted with IMN RT (HR, 1.84; P=.28) in the 3D CRT-planned, left-sided disease subset. CONCLUSIONS No statistically significant association between IMN RT and ICEs was demonstrated in a review of patients treated at a single institution from 1984 to 2007. Given the long natural history and low overall rate of ICEs, continued follow-up of this study, as well as additional studies in the 3D CRT era, is warranted to confirm these results. Minimizing cardiac exposure, when treating a limited IMN field, is critical to limit excess risk of ICEs.
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Affiliation(s)
- Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Adam L Liss
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Center for Cancer Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Robin B Marsh
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Charles Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Todd M Koelling
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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Zhou ZR, Yang ZZ, Yu XL, Guo XM. Is internal mammary nodes irradiation as a part of breast cancer postoperative radiotherapy necessary? J Thorac Dis 2016; 8:3427-3430. [PMID: 28066623 DOI: 10.21037/jtd.2016.11.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Postoperative radiotherapy plays an important role in the multidisciplinary treatment of breast cancer. However, it remains a controversy whether it is necessary to carry out prophylactic internal mammary nodes irradiation (IMNI). This review will focus on this topic. In our opinion, the total risk of relapse should be considered during the decision-making on IMNI; in particular, IMNI is recommended for high-risk patients whose tumor is located at the central/medial area or in patients with positive axillary lymph nodes.
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Affiliation(s)
- Zhi-Rui Zhou
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China;; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zhao-Zhi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China;; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xiao-Li Yu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China;; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xiao-Mao Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai 200032, China;; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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Leite ETT, Ugino RT, Santana MA, Ferreira DV, Lopes MR, Pelosi EL, da Silva JLF, Carvalho HDA. Incidental irradiation of internal mammary lymph nodes in breast cancer: conventional two-dimensional radiotherapy versus conformal three-dimensional radiotherapy. Radiol Bras 2016; 49:170-5. [PMID: 27403017 PMCID: PMC4938447 DOI: 10.1590/0100-3984.2015.0003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate incidental irradiation of the internal mammary lymph nodes (IMLNs) through opposed tangential fields with conventional two-dimensional (2D) or three-dimensional (3D) radiotherapy techniques and to compare the results between the two techniques. MATERIALS AND METHODS This was a retrospective study of 80 breast cancer patients in whom radiotherapy of the IMLNs was not indicated: 40 underwent 2D radiotherapy with computed tomography for dosimetric control, and 40 underwent 3D radiotherapy. The total prescribed dose was 50.0 Gy or 50.4 Gy (2.0 or 1.8 Gy/day, respectively). We reviewed all plans and defined the IMLNs following the Radiation Therapy Oncology Group recommendations. For the IMLNs, we analyzed the proportion of the volume that received 45 Gy, the proportion of the volume that received 25 Gy, the dose to 95% of the volume, the dose to 50% of the volume, the mean dose, the minimum dose (Dmin), and the maximum dose (Dmax). RESULTS Left-sided treatments predominated in the 3D cohort. There were no differences between the 2D and 3D cohorts regarding tumor stage, type of surgery (mastectomy, breast-conserving surgery, or mastectomy with immediate reconstruction), or mean delineated IMLN volume (6.8 vs. 5.9 mL; p = 0.411). Except for the Dmin, all dosimetric parameters presented higher mean values in the 3D cohort (p < 0.05). The median Dmax in the 3D cohort was 50.34 Gy. However, the mean dose to the IMLNs was 7.93 Gy in the 2D cohort, compared with 20.64 Gy in the 3D cohort. CONCLUSION Neither technique delivered enough doses to the IMLNs to achieve subclinical disease control. However, all of the dosimetric parameters were significantly higher for the 3D technique.
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Affiliation(s)
- Elton Trigo Teixeira Leite
- MD, Radiation Oncologist, Radiation Oncology Department - Hospital Sírio-Libanês; Radiation Oncology Department - Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira (Icesp), São Paulo, SP, Brazil
| | - Rafael Tsuneki Ugino
- MD, Radiation Oncologist, Radiation Oncology Department - Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Marco Antônio Santana
- MD, Radiation Oncologist, Department of Radiology and Oncology - Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Denis Vasconcelos Ferreira
- MD, Radiation Oncologist, Department of Radiology and Oncology - Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Maurício Russo Lopes
- MD, Radiation Oncologist, Radiation Oncology Department - Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Edilson Lopes Pelosi
- MD, Radiation Oncologist, Radiation Oncology Department - Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | - Heloisa de Andrade Carvalho
- MD, PhD, Department of Radiology and Oncology - Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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Role of Internal Mammary Node Radiation as a Part of Modern Breast Cancer Radiation Therapy: A Systematic Review. Int J Radiat Oncol Biol Phys 2016; 95:617-31. [DOI: 10.1016/j.ijrobp.2016.01.058] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 01/12/2016] [Accepted: 01/28/2016] [Indexed: 01/14/2023]
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Dess RT, Speers CW, Pierce LJ. Regional Nodal Radiotherapy in Early-Stage Breast Cancer: Where Are We in 2016? CURRENT BREAST CANCER REPORTS 2016. [DOI: 10.1007/s12609-016-0209-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sapienza LG, Chen MJ, Gomes MJL, Mansur DB. Unintended irradiation of internal mammary chain - Is that enough? Rep Pract Oncol Radiother 2016; 21:25-30. [PMID: 26900354 DOI: 10.1016/j.rpor.2015.07.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 07/23/2015] [Indexed: 11/29/2022] Open
Abstract
AIM To evaluate the unintentional coverage of the internal mammary chain (IMC) with tangential fields irradiation to the breast, and its relation with the type of surgery employed. BACKGROUND The dose distribution in regions adjacent to the treatment targets (mammary gland or chest wall), with incidental irradiation of the IMC, could translate into clinical benefit, due to the proximity of these regions. MATERIALS AND METHODS One hundred and twelve consecutive conformal radiotherapy plans were correlating the average dose to the IMC with the type of surgery employed, the extent of disease and the irradiation techniques. RESULTS The mean doses to IMC after modified radical mastectomy (MRM), modified radical mastectomy with immediate reconstruction (MRM + R), and breast conservative surgery (BCS) were 30.34 Gy, 30.26 Gy, and 18.67 Gy, respectively. Significant differences were identified between patients who underwent MRM or MRM + R over BCS (p = 0.01 and 0.003, respectively), but not between MRM and MRM + R (p = 0.88). Mean doses to IMC were greater in patients with T3-T4 tumors when compared with more initial stages (≤T2) (p = 0.0096). The lymph node involvement also correlated with higher average doses to IMC (node positive: 26.1 Gy × node negative: 17.8 Gy, p = 0.0017). CONCLUSIONS The moderate dose level to the IMC in the unintentional irradiation scenario seems to be insufficient to treat the subclinical disease, although it could have an impact in patients undergoing mastectomy.
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Affiliation(s)
- Lucas Gomes Sapienza
- Instituto COI, MD.X Barra Medical Center, Av. das Américas, 6.205 Loja E - Barra da Tijuca, 22793-080 Rio de Janeiro, Brazil; Antonio Cândido Camargo Cancer Center - ACCCC, R. Professor Antônio Prudente, 211 - Liberdade, São Paulo, SP CEP 01509-010, Brazil
| | - Michael Jenwei Chen
- Antonio Cândido Camargo Cancer Center - ACCCC, R. Professor Antônio Prudente, 211 - Liberdade, São Paulo, SP CEP 01509-010, Brazil
| | - Maria José Leite Gomes
- Hospital Federal Servidores do Estado do Rio de Janeiro - HFSE, Rua Sacadura Cabral, 178, CEP 20221-903 Rio de Janeiro, RJ, Brazil
| | - David B Mansur
- U.H. Seidman Cancer Cente, 11100 Euclid Ave., Cleveland, OH 44106, United States
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Arora D, Frakes J, Scott J, Opp D, Johnson C, Song J, Harris E. Incidental radiation to uninvolved internal mammary lymph nodes in breast cancer. Breast Cancer Res Treat 2015; 151:365-72. [DOI: 10.1007/s10549-015-3400-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 04/21/2015] [Indexed: 11/29/2022]
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Thorsen LBJ, Thomsen MS, Overgaard M, Overgaard J, Offersen BV. Quality assurance of conventional non-CT-based internal mammary lymph node irradiation in a prospective Danish Breast Cancer Cooperative Group trial: the DBCG-IMN study. Acta Oncol 2013; 52:1526-34. [PMID: 23957621 DOI: 10.3109/0284186x.2013.813643] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED In 2003, the Danish Breast Cancer Cooperative Group (DBCG) initiated DBCG-IMN, a prospective study on the effect of adjuvant internal mammary lymph node radiotherapy (IMN-RT) in patients with early lymph node positive breast cancer (BC). In the study, standard DBCG IMN-RT was provided only to patients with right-sided BC. We provide estimates of doses to IMNs and organs at risk (OARs) in patients treated with the non-CT-based RT techniques used during the DBCG-IMN study. MATERIAL AND METHODS Five DBCG RT regimens were simulated on planning CT scans from 50 consecutively scanned BC patients, 10 in each group. Intended target volumes were chest wall or breast and regional lymph nodes ± IMNs. Field planning was conducted in the Eclipse(TM) RT treatment planning system. Subsequently, IMN clinical target volumes (CTVs) and OARs were delineated. Estimates on doses to the IMN-CTV and OARs were made. RESULTS IMN dose coverage estimates were consistently higher in right-sided techniques where IMN treatment was intended (p < 0.0001). Estimated doses to cardiac structures were low regardless of whether IMNs were treated or not. Post-lumpectomy patients had the highest estimated lung doses. CONCLUSION Overall, simulator-based treatment using the DBCG RT techniques resulted in satisfactory coverage of IMNs and acceptable levels of OAR irradiation.
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Affiliation(s)
- Lise B J Thorsen
- Department of Experimental Clinical Oncology, Aarhus University Hospital , Aarhus , Denmark
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Tzikas A, Komisopoulos G, Ferreira BC, Hyödynmaa S, Axelsson S, Papanikolaou N, Lavdas E, Lind BK, Mavroidis P. Radiobiological Evaluation of Breast Cancer Radiotherapy Accounting for the Effects of Patient Positioning and Breathing in Dose Delivery. A Meta Analysis. Technol Cancer Res Treat 2013; 12:31-44. [DOI: 10.7785/tcrt.2012.500274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
In breast cancer radiotherapy, significant discrepancies in dose delivery can contribute to underdosage of the tumor or overdosage of normal tissue, which is potentially related to a reduction of local tumor control and an increase of side effects. To study the impact of these factors in breast cancer radiotherapy, a meta analysis of the clinical data reported by Mavroidis et al. (2002) in Acta Oncol (41:471–85), showing the patient setup and breathing uncertainties characterizing three different irradiation techniques, were employed. The uncertainties in dose delivery are simulated based on fifteen breast cancer patients (5 mastectomized, 5 resected with negative node involvement (R-) and 5 resected with positive node involvement (R+)), who were treated by three different irradiation techniques, respectively. The positioning and breathing effects were taken into consideration in the determination of the real dose distributions delivered to the CTV and lung in each patient. The combined frequency distributions of the positioning and breathing distributions were obtained by convolution. For each patient the effectiveness of the dose distribution applied is calculated by the Poisson and relative seriality models and a set of parameters that describe the dose-response relations of the target and lung. The three representative radiation techniques are compared based on radiobiological measures by using the complication-free tumor control probability, P+ and the biologically effective uniform dose, D̿ concepts. For the Mastectomy case, the average P+ values of the planned and delivered dose distributions are 93.8% for a D̿CTV of 51.8 Gy and 85.0% for a D̿CTV of 50.3 Gy, respectively. The respective total control probabilities, PB values are 94.8% and 92.5%, whereas the corresponding total complication probabilities, PI values are 0.9% and 7.4%. For the R- case, the average P+ values are 89.4% for a D̿CTV of 48.9 Gy and 88.6% for a D̿CTV of 49.0 Gy, respectively. The respective PB values are 89.8% and 89.9%, whereas the corresponding PI values are 0.4% and 1.2%. For the R+ case, the average P+ values are 86.1% for a D̿CTV of 49.2 Gy and 85.5% for a D̿CTV of 49.1 Gy, respectively. The respective PB values are 90.2% and 90.1%, whereas the corresponding PI values are 4.1% and 4.6%. The combined effects of positioning uncertainties and breathing can introduce a significant deviation between the planned and delivered dose distributions in lung in breast cancer radiotherapy. The positioning and breathing uncertainties do not affect much the dose distribution to the CTV. The simulated delivered dose distributions show larger lung complication probabilities than the treatment plans. This means that in clinical practice the true expected complications are underestimated. Radiation pneumonitis of Grade 1–2 is more frequent and any radiotherapy optimization should use this as a more clinically relevant endpoint.
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Affiliation(s)
- Athanasios Tzikas
- Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University, Sweden
| | | | | | - Simo Hyödynmaa
- Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Sofie Axelsson
- Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University, Sweden
| | - Nikos Papanikolaou
- Department of Radiological Sciences, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Eleftherios Lavdas
- Department of Radiology, University Hospital of Larissa, Larissa, Greece
| | - Bengt K. Lind
- Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University, Sweden
| | - Panayiotis Mavroidis
- Department of Medical Radiation Physics, Karolinska Institutet and Stockholm University, Sweden
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Research on different techniques in breast cancer radiotherapy. Contemp Oncol (Pozn) 2013; 17:291-7. [PMID: 24596517 PMCID: PMC3934063 DOI: 10.5114/wo.2013.35277] [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: 09/26/2012] [Revised: 10/28/2012] [Accepted: 11/06/2012] [Indexed: 11/29/2022] Open
Abstract
In breast cancer radiotherapy, the internal mammary lymphatic chain is treated in the target volume in a group of patients with high risk criteria. There are a number of different techniques in breast radiotherapy because of the variability of the anatomic region, structures and risk criteria in the irradiation field. When irradiating the target volume we also consider homogeneity of dose distribution and minimizing the dose to critical structures such as the heart and lung. In this study, we have evaluated the dose distribution of different radiotherapy techniques in twelve patients with left breast cancer who had breast conserving surgery or mastectomy. A two-dimensional computerized planning system (2-DCPS) was used for each patient to compare wide-field, oblique photon-electron, perpendicular photon-electron and oblique-electron techniques in terms of dose homogeneities in the target volume, the doses received by the heart and lung, and the coverage of the internal mammary chain. Critical structures were irradiated with acceptable dose percentages besides the internal mammary chain with both wide-field, photon-electron and oblique-electron techniques. The wide-field technique was easy to perform and exposed the heart to a smaller radiation dose than photon-electron techniques. The oblique electron techniques provide a minimal radiation dose to critical structures. In oblique electron techniques, if the internal mammary chain was not covered in the target volume, the heart dose was minimized. In conclusion, we suggest using oblique-electron techniques in breast irradiation where the internal mammary is in the target volume.
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Cancer du sein traité exclusivement par l’association d’une irradiation externe et d’une curiethérapie exclusive : résultats à long terme. Cancer Radiother 2012; 16:674-80. [DOI: 10.1016/j.canrad.2012.07.187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 07/17/2012] [Accepted: 07/18/2012] [Indexed: 11/24/2022]
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Kishi K, Tanino H, Sonomura T, Shirai S, Noda Y, Sato M, Okamura Y. Novel eradicative high-dose rate brachytherapy for internal mammary lymph node metastasis from breast cancer. World J Radiol 2012; 4:443-9. [PMID: 23251722 PMCID: PMC3524510 DOI: 10.4329/wjr.v4.i11.443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 09/18/2012] [Accepted: 09/26/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To develop a method of delivering an eradicative high radiotherapeutic dose safely preserving the surrounding skin in the treatment of internal mammary lymph node metastasis (IMLNM) of breast cancer.
METHODS: We report a 38-year-old female patient with a solo IMLNM showing no response to 60 Gy in 2.5 Gy fractions of external beam radiotherapy. To eradicate this tumor, a boost brachytherapy plan was created after percutaneous insertion of an applicator needle into the IMLNM lesion avoiding the pleura and vessels under ultrasound monitoring. According to the dose distribution, the required thickness of a spacer between the skin and the tumor was determined, and hyaluronic gel was injected up to this thickness under ultrasound monitoring. We evaluated skin doses, target doses and clinical outcome.
RESULTS: All procedures were performed easily. Sixteen Gy (34.7 Gy equivalent in 2 Gy fractions calculated by the linear quadratic model at α/β = 10: EQD2, α/β = 10, cumulative total was 101.9 Gy EQD10) to 100% of the target volume was irradiated with cumulative maximum skin dose of 70 Gy EQD2, α/β = 3 which was 98.7 Gy EQD2, α/β = 3 without spacer. No procedure related- or late complications and no local recurrence at the treated site were observed for three years until expiration.
CONCLUSION: We consider that this procedure will provide an eradicative high-dose irradiation to IMLNM of breast cancer, preserving skin from overdose complications.
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Postma EL, van Wieringen S, Hobbelink MG, Verkooijen HM, van den Bongard HJGD, Borel Rinkes IHM, Witkamp AJ. Sentinel lymph node biopsy of the internal mammary chain in breast cancer. Breast Cancer Res Treat 2012; 134:735-41. [PMID: 22678155 PMCID: PMC3401492 DOI: 10.1007/s10549-012-2086-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 04/30/2012] [Indexed: 01/08/2023]
Abstract
Routine removal of the internal mammary chain (IMC) sentinel node in breast cancer patients remains a subject of discussion. The aim of this study was to determine the impact of routinely performed IMC sentinel node biopsy on the systemic and locoregional treatments plan. All patients with biopsy proven breast cancer who underwent a sentinel node procedure between 2002 and 2011 were included in a prospective database. In cases of IMC drainage, successful exploration of the IMC (i.e., sentinel node removed) and surgical complications were registered. If the removed sentinel node contained malignant cells we determined if this altered the treatment plan when practising the current guidelines. In total, 119 of the 493 included patients showed IMC drainage on lymphoscintigraphy. Exploration of the IMC was performed in 107 (89 %) patients; in 86/107 (80 %) exploration was successful. In 14/107 patients (13 %) the IMC sentinel node was tumor positive. Macro and micro metastases were found in eight and six patients, respectively. In the group of patients who underwent surgical exploration of the IMC, systemic treatment was changed in none, radiotherapy treatment in 13/107 patients (11 %). Routine sentinel node biopsy of the IMC does not alter the systemic treatment. Radiotherapy treatment is altered in a small proportion of the patients; however, solid scientific evidence for this adjustment is lacking.
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Affiliation(s)
- E L Postma
- Department of Surgery, University Medical Centre Utrecht, Postbus 85500, 3508 GA Utrecht, The Netherlands.
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18
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Auberdiac P, Cartier L, Chargari C, Hau Desbat NH, Zioueche A, Mélis A, Kirova YM, de Laroche G, Magné N. Radiothérapie de la chaîne mammaire interne dans les cancers du sein : état des lieux. Cancer Radiother 2011; 15:148-53. [DOI: 10.1016/j.canrad.2010.07.634] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 07/01/2010] [Accepted: 07/04/2010] [Indexed: 11/26/2022]
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Abstract
The role of immune surveillance in controlling the spread of breast cancer to the regional nodes is poorly understood. In theory regional nodal irradiation (RNI) might compromise this host function. However the clinical evidence suggests that the risk of regional recurrence is lower in patients with early breast cancer whose axilla has been irradiated compared to no axillary treatment. The role of RNI after breast conserving surgery has not been well studied. A policy of level III clearance and only irradiating the axilla for residual disease and a selective policy of axillary irradiation in node positive patients after sentinel node biopsy or lower axillary node sample is recommended. Irradiation of the medial supraclavicular fossa after axillary dissection is suggested where there are four or more nodes involved on axillary dissection. There is little data to inform selection of patients for RNI after neoadjuvant systemic therapy. The role of postmastectomy radiotherapy (PMRT) was largely established on the basis of comprehensive RNI. It is unclear whether irradiating less than the chest wall and peripheral lymphatics confers the same level of benefit. The role of PMRT in women with 1-3 involved nodes remains controversial and investigational. Biological factors such as oestrogen and progesterone receptor status and HER-2 protein expression may play a role in determining benefits from PMRT. The role of internal mammary nodal irradiation is unclear. The individualisation of RNI based on molecular and genetic factors should be a priority for research. The benefits of RNI need to be carefully balanced against the risks of cardiotoxicity, pneumonitis, lymphoedema, brachial plexopathy and secondary malignancy.
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Affiliation(s)
- Ian H Kunkler
- Edinburgh Cancer Centre, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh, Scotland, UK.
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Vinh-Hung V, Truong PT, Janni W, Nguyen NP, Vlastos G, Cserni G, Royce ME, Woodward WA, Promish D, Tai P, Soete G, Balmer-Majno S, Cutuli B, Storme G, Bouchardy C. The effect of adjuvant radiotherapy on mortality differs according to primary tumor location in women with node-positive breast cancer. Strahlenther Onkol 2009; 185:161-8; discussion 169. [PMID: 19330292 DOI: 10.1007/s00066-009-1921-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Accepted: 11/07/2008] [Indexed: 02/03/2023]
Abstract
PURPOSE To evaluate the prognostic significance of primary tumor location and to examine whether the effect of adjuvant radiotherapy on survival varies according to tumor location in women with axillary node-positive (ALN+) breast cancer (BC). PATIENTS AND METHODS Data were abstracted from the SEER database for 24,410 women aged 25-95 years, diagnosed between 1988-1997 with nonmetastatic T1-T2, ALN+ BC. Subgroup analyses were performed using interactions within proportional hazards models. Event was defined as death from any cause. Prognostic variables were selected using Akaike Information Criteria. Joint significances of subgroups were evaluated with Wald test. RESULTS Median follow-up was 10 years. In joint models, statistically significant interactions were found between tumor location, nodal involvement, type of surgery, and radiotherapy. Factorial presentation of interactions showed consistent 13% proportional reduction of mortality in all subgroups, except in women with medial tumors with > or = 4 ALN+ treated with mastectomy. In this subgroup, use of radiotherapy was associated with a 16% proportional increase in mortality. CONCLUSION Medial tumor location is a significant adverse prognostic factor that should be considered in treatment decision- making for women with ALN+ BC. Improved survival was observed with radiotherapy use in all subgroups, except in women with medial tumors with > or = 4 ALN+ treated with postmastectomy radiotherapy. These findings raise concern that the favorable effect of radiotherapy may be offset by excess toxicities in the latter subgroup.
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21
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Can the sentinel lymph node technique affect decisions to offer internal mammary chain irradiation? Eur J Nucl Med Mol Imaging 2009; 36:758-64. [DOI: 10.1007/s00259-008-1034-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 11/28/2008] [Indexed: 11/26/2022]
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Chen RC, Lin NU, Golshan M, Harris JR, Bellon JR. Internal mammary nodes in breast cancer: diagnosis and implications for patient management -- a systematic review. J Clin Oncol 2008; 26:4981-9. [PMID: 18711171 DOI: 10.1200/jco.2008.17.4862] [Citation(s) in RCA: 176] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The management of internal mammary nodes (IMNs) in breast cancer is controversial. Surgical series from the 1950s showed that one third of breast cancer patients had IMN involvement, with a higher risk in patients with medial tumors and/or positive axillary nodes. IMN metastasis has similar prognostic importance as axillary nodal involvement. However, after three randomized trials showed no survival benefit from extended mastectomy compared with radical or modified radical mastectomy, IMN dissection was largely abandoned. Recently, lymphoscintigraphy studies have renewed interest in IMN evaluation. Approximately one fifth of internal mammary sentinel nodes are pathologic, although most centers do not perform IMN biopsies because of concerns about morbidity and lack of established survival benefit. In addition, results from randomized trials testing the value of postmastectomy irradiation and a meta-analysis of 78 randomized trials have provided high levels of evidence that local-regional tumor control is associated with long-term survival improvements. This benefit was limited to trials that used systemic therapy, which was not routinely administered in the earlier surgical studies, although the contribution from IMN treatment is unclear. IMN irradiation has also been shown to cause increased cardiac morbidity. Before mature results from current randomized trials assessing the benefit of IMN irradiation become available, lymphoscintigraphy may be used to help guide decisions regarding systemic and local-regional treatment. However, even in patients with visualized primary IMN drainage, the potential benefit of treatment should be balanced against the risk of added morbidity.
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Affiliation(s)
- Ronald C Chen
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
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23
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Kunkler IH, Canney P, van Tienhoven G, Russell NS, MRC/EORTC (BIG 2-04) SUPREMO Trial Management Group. Elucidating the role of chest wall irradiation in 'intermediate-risk' breast cancer: the MRC/EORTC SUPREMO trial. Clin Oncol (R Coll Radiol) 2008; 20:31-4. [PMID: 18345543 DOI: 10.1016/j.clon.2007.10.004] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Yadav BS, Sharma SC, Patel FD, Ghoshal S, Kapoor RK. Second primary in the contralateral breast after treatment of breast cancer. Radiother Oncol 2008; 86:171-176. [PMID: 17961777 DOI: 10.1016/j.radonc.2007.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Revised: 09/29/2007] [Accepted: 10/03/2007] [Indexed: 11/21/2022]
Abstract
PURPOSE To study the potential risk factors for contralateral breast cancer (CBC) in women after treatment of the primary breast cancer. PATIENTS AND METHODS Between January 1985 and December 1995, records of 1084 breast cancer patients at our institution were analyzed for incidence of CBC. In all the patients a detailed analysis was carried out with respect to age, disease stage, radiation therapy technique, dose, the use of chemotherapy or hormone therapy, and other clinical and/or pathologic characteristics. The Kaplan-Meier method was used to estimate the acturial rate of CBC. The Cox proportional hazard regression model was used to estimate the relative risk (RR) of CBC. RESULTS Up to December 2005, the median follow up was 12 years. Overall incidence of CBC was 4%. The 10 and 20 year acturial rate of CBC was 5.6% and 11.3%, respectively. The CBC rate at 10 and 20 year was 5.4% and 10.2%, respectively, for patients with mastectomy only and 5.1% and 9.7%, respectively, in the mastectomy plus RT group (p=0.3). In the subset of patients <45 years of age at the time of treatment, 10 and 20 year acturial rate of CBC was 5% and 9%, respectively, for patients who underwent mastectomy only and 6.3% and 11%, respectively, for patients treated with mastectomy plus RT (RR=1.4, 95% CI: 1.14-1.45, p=0.003). There was statistically significant lower rate of CBC in patients given adjuvant hormonal therapy (8.5%) as compared to those without hormonal therapy (14.3%, p=0.004) at 20 year. Women with family history of breast cancer had highest rate (15.3%) of CBC (RR=1.6, 95% CI: 1.12-1.27) at 20 years. The adjuvant use of chemotherapy did not significantly affect the risk of second malignancy. CONCLUSION There seems to be little risk of second malignancies in patients treated with mastectomy plus RT using modern techniques, compared with mastectomy only, that was only prevalent in patients <45 years of age. Family history of breast cancer seems to be the highest risk factor for CBC.
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Affiliation(s)
- Budhi Singh Yadav
- Post Graduate Institute of Medical Education and Research, Department of Radiotherapy, Chandigarh, India.
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25
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Poortmans P. Evidence based radiation oncology: Breast cancer. Radiother Oncol 2007; 84:84-101. [PMID: 17599597 DOI: 10.1016/j.radonc.2007.06.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/30/2007] [Accepted: 06/02/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Radiotherapy is, similar to surgery, a local treatment. In the case of breast cancer, it is generally given after conservative or after more extensive, tumour and patient adapted, surgery. The target volumes can be the breast and/or the thoracic wall and/or the regional lymph node areas. The integration and the extent of radiotherapy as part of the comprehensive treatment of the breast cancer patient, including the amount of surgery and the sequencing with the systemic treatments, has to be well discussed with all medical specialists involved in treating breast cancer on a multidisciplinary basis. Guidelines for the appropriate prescription and execution of radiotherapy are of utmost importance. However, individualisation based on the individual patients' and tumours' characteristics should always be envisaged. MATERIALS AND METHODS Based on a review of the literature the level of evidence that is available for the indications for radiotherapy is summarised, as well as the main clinical questions that are unanswered today. An overview of the recent and ongoing clinical trails in breast cancer will highlight some of the current ongoing debates. CONCLUSIONS In the case of breast cancer, radiotherapy, given after as well conservative as extensive risk-adapted surgery, significantly reduces the risk of local and regional recurrences. Especially for patients with an intermediate to high absolute risk for local recurrences, a positive influence on overall survival has been shown, notably when appropriate radiotherapy techniques are used. Most important is that the best results that we can offer to our breast cancer patients for all clinical endpoints (local and regional control; quality of life; cosmetic results; survival) can be obtained by a multidisciplinary and patient-oriented approach, involving all those involved in the treatment of breast cancer patients.
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Affiliation(s)
- Philip Poortmans
- Dr. Bernard Verbeeten Instituut, Radiotherapy, Tilburg, Netherlands.
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26
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Kahán Z, Varga Z, Csenki M, Szabó J, Szil E, Fekete G, Hideghéty K, Boda K, Thurzó L. [Approaches to individual radiotherapy in breast cancer: individual risk estimation and individualized techniques]. Orv Hetil 2007; 148:833-41. [PMID: 17468066 DOI: 10.1556/oh.2007.27877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Radiotherapy comprises an integral part of the curative therapy of breast cancer by improving the locoregional control and survival when given on an individualized basis. Conformal radiotherapy and three-dimensional radiation treatment planning enhance the safety of radiotherapy by adjusting the irradiated volume to the shape of the target volume, and providing control of the radiation dose to the organs at risk (OARs). PATIENTS AND METHODS The methods introduced at the authors' institute in 2002 are demonstrated. The breast/chest wall and lymph node areas were irradiated provided that there was a minimum risk of local or locoregional relapse of 10%. CT-based 3D radiotherapy treatment planning and individual patient-positioning were applied, with thermoplastic mask-fixation in the second part of the study. The dose constraints of the OARs were given in accordance with the literature recommendations. In the first group of patients, individually shaped blocks, in the second group, multileaf collimator, and in the third group, with the aim of a more homogenous dose-distribution in the target volume, intensity-modulated beams were applied. RESULTS During the study, 737 breast cancer patients received conformal radiotherapy based on individual risk estimation. In 372 cases only local, while in 365 cases locoregional radiotherapy was delivered. The dose-homogeneity in the target volume was significantly improved in the second period of the study, when segments were superposed on the radiotherapy fields. The proportions of the target volumes irradiated with +/-10% of the planned dose in the breast/chest wall, axillary and supraclavicular lymph nodes and internal mammary lymph nodes varied between 90.5-94.2%, 84.1-93.8% and 86.7-91.6%, respectively, depending on the radiation technique used. The parameters indicating the dose to the ipsilateral lung or to the heart were significantly higher when locoregional radiotherapy was applied compared to that in case of local radiotherapy. Radiation dose to the ipsilateral lung and the heart was significantly reduced in the second part of the study when locoregional, but not when local radiotherapy was delivered. The introduction of individual immobilization by means of thermoplastic mask-fixation resulted in a relevant decrease in the uncertainty due to breathing motion and daily positioning errors, and also in a significant reduction of the dose to the contralateral breast. CONCLUSIONS Adjuvant radiotherapy should be based on individual risk-benefit features. The need of the introduction of special techniques may be decided after the dose-volume analysis of the conformal radiotherapy plan based on 3D radiation treatment planning.
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Affiliation(s)
- Zsuzsanna Kahán
- Szegedi Tudományegyetem, Szent-Györgyi Albert Orvos- és Gyógyszerésztudományi Centrum, Altalános Orvostudományi Kar Onkoterápiás Klinika, Szeged.
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27
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Musat E, Poortmans P, Van den Bogaert W, Struikmans H, Fourquet A, Bartelink H, Kirkove C, Budach V, Pierart M, Collette L. Quality assurance in breast cancer: EORTC experiences in the phase III trial on irradiation of the internal mammary nodes. Eur J Cancer 2007; 43:718-24. [PMID: 17240136 DOI: 10.1016/j.ejca.2006.11.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Accepted: 11/13/2006] [Indexed: 11/17/2022]
Abstract
The EORTC 22922/10925 trial randomly compares irradiation or no irradiation of the internal mammary and medio supraclavicular (IM-MS) nodes for stage I-III breast cancer. We report on the characteristics of 4004 participating patients, aspects of quality assurance and compliance to protocol treatment. The actual population has intermediate-risk disease: 51.8% stage II, 56% positive axillary nodes. The allocated treatment was not followed in 3.2% in the IM-MS irradiation arm versus 2% in the no IM-MS irradiation arm. In the IM-MS arm, there were major deviations for dose in 0.8%, surgery-to-radiotherapy time interval in 3.9% and in overall treatment time in 0.9% cases. Major deviations were found in 7.9% patients in the IM-MS group and in 2% patients in the no IM-MS group. In the final trial analysis, a sensitivity analysis should evaluate the subgroup of patients receiving an optimal treatment to verify the robustness of the results and the true impact of IM-MS irradiation.
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Affiliation(s)
- Elena Musat
- EORTC, Avenue E. Mounierlaan, 83/11, 1200 Brussels, Belgium.
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28
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Abstract
In breast cancer patients, the incidence of involvement of the regional lymph nodes and the risk for developing a locoregional recurrence are highly influenced by several prognostic factors. A meta-analysis of the EBCTCG showed a reduction of about 70% of the locoregional recurrence rate with radiotherapy for all patients, independent of age, characteristics of the tumour or the administration of systemic treatment. At the same time, this meta-analysis confirmed that radiotherapy can lead to an increased risk for developing contralateral breast cancer and to an increase in the risk of non-breast cancer related mortality, mainly due to cardiac and pulmonary toxicity. Because of this, the net effect of regional radiotherapy will be strongly influenced by the individual risk factors of the patients and by the quality of the technical aspects of the radiotherapy. The thin line between the benefits of elective regional lymph node irradiation and the possible late toxicity for patients with early stage breast cancer is currently the subject of several prospective randomised trials, the results of which will only become available in several years. Moreover, recent developments in the field of novel prognostic factors will open completely new ways to be explored, which might give us new tools for estimating the individual benefit/risk ratio for every single patient.
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Affiliation(s)
- P-M-P Poortmans
- Département de Radiothérapie, Institut Docteur-Bernard-Verbeeten, 5000 Tilburg, Pays-Bas.
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29
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Järvenpää R, Holli K, Pitkänen M, Hyödynmaa S, Rajala J, Lahtela SL, Ojala A. Radiological pulmonary findings after breast cancer irradiation: A prospective study. Acta Oncol 2006; 45:16-22. [PMID: 16464791 DOI: 10.1080/02841860500334921] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The aim of this study was to evaluate radiation-induced pulmonary abnormalities of breast cancer patients. Altogether 202 consecutive patients receiving postoperative radiotherapy entered the study. Plain chest radiographs taken at entry and 3, 6 and 12 months after radiotherapy were evaluated according to modified Arriagada classification. In addition, pulmonary symptoms were recorded. Supplementary high-resolution computed tomography (HRCT) was employed in a subgroup of patients (n?=?15). Plain radiographs were interpreted by a radiologist, and uncertain findings were re-evaluated by a radiologist together with a radiation oncologist. Grade 2 pneumonitis was the most common abnormality. The proportion of patients yielding a grade 2 finding was 22.5%, 28.1%, and 16.0% at three, six, and twelve months, respectively. There were 2 normal findings in HRCTscans, and 8 in plain radiographs of the same patients. Radiological lung abnormalities are common after radiotherapy, but they are usually reversible, and their significance for the patient's well-being is minor. No correlation between symptoms and lung or pleural reactions was seen.
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Affiliation(s)
- Ritva Järvenpää
- Department of Diagnostic Radiology, Tampere University Hospital, Tampere, Finland.
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30
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Abstract
Radiotherapy given after mastectomy (PMRT) will reduce the risk of local recurrence by about two-thirds. The absolute benefit will depend on the risk of local recurrence, which will depend on pathological characteristics (tumour size, nodal status, etc.) but also the type and extent of the surgery. The overall effect of radiotherapy on survival has changed with time. Improved local control reduces the risk of dying from breast caner, presumably by preventing secondary dissemination from recurrent disease. Older radiotherapy techniques were associated with an excess risk of cardiovascular death, which counterbalanced the improvement in survival seen with better local control. More recent studies show that modern radiotherapy techniques can improve local control and avoid cardiac morbidity. PMRT remains an important component of the management of patients with breast cancer.
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Affiliation(s)
- J A Dewar
- Department of Oncology, Ninewells Hospital, Dundee, Scotland, UK.
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31
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van der Laan HP, Dolsma WV, van 't Veld AA, Bijl HP, Langendijk JA. Comparison of normal tissue dose with three-dimensional conformal techniques for breast cancer irradiation including the internal mammary nodes. Int J Radiat Oncol Biol Phys 2005; 63:1522-30. [PMID: 15994027 DOI: 10.1016/j.ijrobp.2005.04.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2005] [Revised: 04/20/2005] [Accepted: 04/21/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare the Para Mixed technique for irradiation of the internal mammary nodes (IMN) with three commonly used strategies, by analyzing the dose to the heart and other organs at risk. METHODS AND MATERIALS Four different three-dimensional conformal dose plans were created for 30 breast cancer patients. The IMN were enclosed with the Para Mixed technique by a widened mediolateral tangent photon beam and an anterior electron beam, with the Patched technique by an anterior electron beam, with the Standard technique by an anterior photon and electron beam, and with the PWT technique by partially wide tangents. All techniques were optimized for conformality and produced equally adequate target coverage. RESULTS Heart dose was lowest with the Para Mixed and Patched technique for all patients and with the PWT technique for right-sided treatment only. Lung dose was highest with the PWT, lowest with the Patched, and intermediate with the Para Mixed and Standard techniques. Skin dose was highest with the Patched, lowest with the PWT, and intermediate with the Para Mixed and the Standard techniques. The Para Mixed technique resulted in a 13-Gy lower dose in an overlap area, and the PWT technique was the only technique that incorporated considerable volumes of the contralateral breast. CONCLUSION The Para Mixed technique yielded the overall best results. No other technique resulted in a lower heart dose. Lung and skin were equally spared instead of one of them being compromised, and the contralateral breast was avoided.
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Affiliation(s)
- Hans P van der Laan
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, The Netherlands.
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32
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Lievens Y, Kesteloot K, van den Bogaert W. Economic consequence of local control with radiotherapy: Cost analysis of internal mammary and medial supraclavicular lymph node radiotherapy in breast cancer. Int J Radiat Oncol Biol Phys 2005; 63:1122-31. [PMID: 16253774 DOI: 10.1016/j.ijrobp.2005.03.064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Revised: 03/30/2005] [Accepted: 03/31/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To investigate the financial implications of radiotherapy (RT) to the internal mammary and medial supraclavicular lymph node chain (IM-MS) in postoperative breast cancer. METHODS AND MATERIALS A cost-effectiveness and cost-utility analysis were performed, using Markov models, comparing the early and delayed costs and effects of IM-MS during a 20-year time span from a societal viewpoint. The outcome estimates were based on Level I evidence from postoperative RT literature and the cost estimates on the standard practice of the Leuven University Hospitals, with the RT costs derived from an activity-based costing program developed in the department. RESULTS On the basis of the assumptions of the model and seen during a 20-year time span, primary treatment including IM-MS RT results in a cost savings (approximately 10,000) compared with a strategy without RT. Because IM-MS RT also results in better clinical effectiveness and greater quality of life, the treatment with IM-MS dominates the approach without IM-MS. Sensitivity analyses confirmed the robustness of these results in all tested circumstances. Although threshold values were found for the cost of IM-MS, the cost at relapse, and the quality of life after treatment, these were substantially different from the baseline estimates, indicating that it is very unlikely that omitting IM-MS would become superior. CONCLUSION This ex-ante cost evaluation of IM-MS RT showed that the upfront costs of locoregional RT are easily compensated for by avoiding the costs of treating locoregional and distant relapse at a later stage. The cost-sparing effect of RT should, however, be evaluated for a sufficiently long time span and is most specifically found in tumors with a rather slow natural history and a multitude of available systemic treatments at relapse, such as breast cancer.
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Affiliation(s)
- Yolande Lievens
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium.
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Nicolini G, Fogliata A, Cozzi L. Critical appraisal of a non-coplanar technique for radiotherapy of breast minimising lung involvement. Radiother Oncol 2005; 76:319-25. [PMID: 15921771 DOI: 10.1016/j.radonc.2005.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2004] [Revised: 02/28/2005] [Accepted: 04/06/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE To appraise the potential benefit of a conformal technique with non-coplanar fields to minimise lung irradiation in the radiation treatment of breast. PATIENTS AND METHODS A comparative study was carried out at planning level for six patients selected for their inadequate sparing of healthy lung tissue with the reference tangential technique. Plans were designed for the conventional tangential technique, for an alternative conformal approach with three beams and for the newly proposed technique with two non-coplanar beams. RESULTS In average for the new technique compared to the reference, mean lung dose dropped from approximately 16 to 10.5 Gy, V(20 Gy) from 29.5 to 18.2% and the dose delivered to 1/3 (1/4) of the lung volume dropped from 28.5% (67.3%) to 8.7% (13.4%). For PTV, the volume receiving at least 90% of the prescribed dose resulted 97.4% for the new and 97.3% for the reference. Conformity index improved significantly from 2.58 for the reference to 1.84 for the new technique. CONCLUSIONS For a subgroup population of breast cancer patients, where conventional techniques failed to achieve high conformal avoidance, a treatment modality with non-coplanar beams was developed and clinically tested for six patients. It resulted dosimetrically adequate, particularly when the risk of toxicity is relevant.
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Affiliation(s)
- Giorgia Nicolini
- Radiation Oncology Department, Oncology Institute of Southern Switzerland, Medical Physics Unit, Bellinzona, Switzerland
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34
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Taghian A, Jagsi R, Makris A, Goldberg S, Ceilley E, Grignon L, Powell S. Results of a survey regarding irradiation of internal mammary chain in patients with breast cancer: Practice is culture driven rather than evidence based. Int J Radiat Oncol Biol Phys 2004; 60:706-14. [PMID: 15465186 DOI: 10.1016/j.ijrobp.2004.04.027] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2003] [Revised: 02/16/2004] [Accepted: 04/07/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE To examine the self-reported practice patterns of radiation oncologists in North America and Europe regarding radiotherapy to the internal mammary lymph node chain (IMC) in breast cancer patients. METHODS AND MATERIALS A survey questionnaire was sent in 2001 to physician members of the American Society for Therapeutic Radiology and Oncology and European Society for Therapeutic Radiology and Oncology regarding their management of breast cancer. Respondents were asked whether they would treat the IMC in several clinical scenarios. RESULTS A total of 435 responses were obtained from European and 702 responses from North American radiation oncologists. Respondents were increasingly likely to report IMC irradiation in scenarios with greater axillary involvement. Responses varied widely among different European regions, the United States, and Canada (p < 0.01). European respondents were more likely to treat the IMC (p < 0.01) than their North American counterparts. Academic physicians were more likely to treat the IMC than those in nonacademic positions (p < 0.01). CONCLUSION The results of this study revealed significant international variation in attitudes regarding treatment of the IMC. The international patterns of variation mirror the divergent conclusions of studies conducted in the different regions, indicating that physicians may rely preferentially on evidence from local studies when making difficult treatment decisions. These variations in self-reported practice patterns indicate the need for greater data in this area, particularly from international cooperative trials. The cultural predispositions documented in this study are important to recognize, because they may continue to affect physician attitudes and practices, even as greater evidence accumulates.
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Affiliation(s)
- Alphonse Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, 100 Blossom Street, Boston, MA 02114, USA.
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Truong PT, Olivotto IA, Whelan TJ, Levine M. Clinical practice guidelines for the care and treatment of breast cancer: 16. Locoregional post-mastectomy radiotherapy. CMAJ 2004; 170:1263-73. [PMID: 15078851 PMCID: PMC385392 DOI: 10.1503/cmaj.1031000] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE To provide information and recommendations to assist women with breast cancer and their physicians in making decisions regarding the use of locoregional post-mastectomy radiotherapy (PMRT). OUTCOMES Locoregional control, disease-free survival, overall survival and treatment-related toxicities. EVIDENCE This guideline is based on a review of all meta-analyses, consensus statements and other guidelines published between 1966 and November 2002. Searches of MEDLINE and CANCERLIT for English-language randomized controlled trials published between 1995 and November 2002 were also conducted to supplement the literature previously reviewed by the American Society of Clinical Oncology (ASCO) Health Services Research Committee panel in its published guideline. A nonsystematic review of the literature was continued through June 2003. RECOMMENDATIONS Locoregional PMRT is recommended for women with an advanced primary tumour (tumour size 5 cm or greater, or tumour invasion of the skin, pectoral muscle or chest wall). Locoregional PMRT is recommended for women with 4 or more positive axillary lymph nodes. The role of PMRT in women with 1 to 3 positive axillary lymph nodes is unclear. These women should be offered the opportunity to participate in clinical trials of PMRT. Locoregional PMRT is generally not recommended for women who have tumours that are less than 5 cm in diameter and who have negative axillary nodes. Other patient, tumour and treatment characteristics, including age, histologic grade, lymphovascular invasion, hormone receptor status, number of axillary nodes removed, axillary extracapsular extension and surgical margin status, may affect locoregional control, but their use in specifying additional indications for PMRT is currently unclear. PMRT should encompass the chest wall and the supraclavicular, infraclavicular and axillary apical lymph node areas. To reduce the risk of lymphedema, radiation of the entire axilla should not be used routinely after complete axillary dissection of level I and II lymph nodes. A definite recommendation regarding the inclusion of the internal mammary lymph nodes in PMRT cannot be made because of limited and inconsistent data. The use of modern techniques in radiotherapy planning is recommended to minimize excessive normal tissue exposure, particularly to the cardiac and pulmonary structures. Common short-term side effects of PMRT, including fatigue and skin erythema, are generally tolerable and not dose-limiting. Severe long-term side effects, including lymphedema, cardiac and pulmonary toxicities, brachial plexopathy, rib fractures and secondary neoplasms, are relatively rare. The optimal sequencing of PMRT and systemic therapy is currently unclear. Regimens containing anthracyclines or taxanes should not be administered concurrently with radiotherapy because of the potential for increased toxicity. VALIDATION The authors' original text was submitted for review, revision and approval by the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Subsequently, feedback was provided by 11 oncologists from across Canada. The final document was approved by the steering committee. SPONSOR The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer was convened by Health Canada. COMPLETION DATE: November 2003.
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Frazier RC, Vicini FA, Sharpe MB, Yan D, Fayad J, Baglan KL, Kestin LL, Remouchamps VM, Martinez AA, Wong JW. Impact of breathing motion on whole breast radiotherapy: a dosimetric analysis using active breathing control. Int J Radiat Oncol Biol Phys 2004; 58:1041-7. [PMID: 15001243 DOI: 10.1016/j.ijrobp.2003.07.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2003] [Revised: 07/25/2003] [Accepted: 07/29/2003] [Indexed: 11/30/2022]
Abstract
PURPOSE The active breathing control (ABC) apparatus was used to quantify the effect of breathing motion on whole breast radiotherapy (RT) with standard wedges and intensity-modulated RT (IMRT). METHODS AND MATERIALS Ten patients with early-stage breast cancer underwent routine free-breathing (FB) CT simulations for whole breast RT. An ABC apparatus was used to obtain two additional CT scans with the breath held at the end of normal inhalation and normal exhalation. The FB scan was used to develop both a standard treatment plan using wedged coplanar tangents and an IMRT plan using multiple static multileaf collimator segments. To simulate breathing, each plan was copied and applied to the normal inhalation and normal exhalation CT scans. RESULTS The medial field border (defined by a radiopaque catheter) for the normal inhalation and normal exhalation scans moved an average of 0.6 cm anteriorly and 0.3 cm posteriorly compared with the FB position, respectively. The corresponding movement of the lateral field border was an average of 0.4 cm anteriorly and 0.2 cm posteriorly compared with the FB position. For both the wedged and the IMRT techniques, the dose delivered to breast tissue, biopsy cavity, and ipsilateral lung was similar for each of the three CT scan positions. However, the internal mammary node dose varied significantly with breathing. CONCLUSIONS The dose delivered to breast using standard wedges or step-and-shoot IMRT is relatively insensitive to the effects of breast motion during normal breathing. However, an appreciable portion of the internal mammary nodes are irradiated during normal inhalation, contributing to the uncertainty in the analysis of the efficacy of internal mammary nodal RT in breast treatment.
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Affiliation(s)
- Robert C Frazier
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA
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Olivotto IA, Chua B, Elliott EA, Parda DS, Pierce LJ, Shepherd L, Vallow LA, White JR, Whelan TJ. A Clinical Trial of Breast Radiation Therapy Versus Breast and Regional Radiation Therapy in Early-Stage Breast Cancer: The MA20 Trial. Clin Breast Cancer 2003; 4:361-3. [PMID: 14715112 DOI: 10.3816/cbc.2003.n.042] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Ivo A Olivotto
- Radiation Oncology, British Columbia Cancer Agency and University of British Columbia, Vancouver Island Centre, 2410 Lee Avenue, Victoria, BC V8R 6V5, Canada.
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Bora H, Akmansu M, Gürel O. Evaluation of Standard Tangential Irradiation versus Breast Ring Technique Using Three-Dimensional Tools in Cancerous Large Breasts. TUMORI JOURNAL 2003; 89:510-3. [PMID: 14870773 DOI: 10.1177/030089160308900509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background In patients with large breasts, tangential irradiation after lumpectomy is technically difficult. Tangential plans of large breasts comprise a large volume of the lung, axilla and heart, as well as an important volume of the opposite breast and lung. Methods Instead of classical positioning of the breast, we encircled the breast with a plastic polyvinyl ring-shaped tube. All five left-sided breast cancer patients underwent CT scan planning with and without the plastic ring in conventional treatment positioning. Skin treatment portals at the midline and mid axilla were marked with radio-opaque markers. The scan volume encompassed the region from just below the diaphragm to the lung apex. Patients' plans were evaluated with regard to dose-volume coverage of the breast planning target volume, ipsilateral lung, contralateral lung, heart and contralateral breast. End points were maximum dose, minimum dose, and mean dose delivered to the target or critical structure. Results As expected, the average volume of the left lung treated above a tolerance dose of 2000 cGy was less than 10% in the ringed breast, whereas in the other method without the ring the corresponding lung volume was 30%. The cardiac volume receiving a dose over 4000 cGy was 2% in the ringed breast and 18% in the breast without a ring. Conclusions With the use of a simple technique with a fairly low expenditure, acute skin reactions and late cardiac and lung morbidity can be minimized in patients with large breasts.
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Affiliation(s)
- Huseyin Bora
- Department of Radiation Oncology, Gazi University Medical Faculty, Ankara, Turkey.
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Poortmans P, Kouloulias VE, Venselaar JL, Struikmans H, Davis JB, Huyskens D, van Tienhoven G, Hurkmans C, Mijnheer B, Van den Bogaert W. Quality assurance of EORTC trial 22922/10925 investigating the role of internal mammary--medial supraclavicular irradiation in stage I-III breast cancer: the individual case review. Eur J Cancer 2003; 39:2035-42. [PMID: 12957458 DOI: 10.1016/s0959-8049(03)00455-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To assess consistency among participants in an European Organisation for Research and Treatment of Cancer (EORTC) phase III trial randomising between irradiation and no irradiation of the internal mammary and medial supraclavicular (IM-MS) lymph nodes, all participating institutes were invited to send data from 3 patients in each arm as soon as they started accrual. The evaluation focused on eligibility, compliance with the radiotherapy guidelines, treatment techniques and dose prescription to the IM-MS region. Nineteen radiotherapy departments provided a total of 111 cases, all being eligible. Minor discrepancies were found in the surgery and pathology data in almost half the patients. Major radiotherapy protocol deviations were very limited: 2 cases of unwarranted irradiation of the supraclavicular region and a significant dose deviation to the internal mammary region in 5 patients. The most frequently observed minor protocol deviation was the absence of delineation of the target volumes in 80% of the patients. By detecting systematic protocol deviations in an early phase of the trial, recommendations made to all the participating institutes should improve the interinstitutional consistency and promote a high-quality treatment.
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Affiliation(s)
- P Poortmans
- Department of Radiotherapy, Dr. Bernard Verbeeten Instituut, PO Box 90120, 5000 LA, Tilburg, The Netherlands.
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Stemmer SM, Rizel S, Hardan I, Adamo A, Neumann A, Goffman J, Brenner HJ, Pfeffer MR. The role of irradiation of the internal mammary lymph nodes in high-risk stage II to IIIA breast cancer patients after high-dose chemotherapy: a prospective sequential nonrandomized study. J Clin Oncol 2003; 21:2713-8. [PMID: 12860949 DOI: 10.1200/jco.2003.09.096] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This phase II single-institution prospective, nonrandomized trial investigates high-dose adjuvant chemotherapy and locoregional radiotherapy in patients with breast cancer. We compared the outcome of patients in this study treated with radiotherapy fields including the internal mammary nodes (IMN) to a group of patients who did not receive IMN irradiation. PATIENTS AND METHODS 100 patients with high-risk stage II-III breast cancer received doxorubicin-based adjuvant chemotherapy followed by high-dose chemotherapy, stem-cell support, and locoregional radiotherapy. The radiotherapy included electron-beam irradiation to the IMN. For 20 months during the study, no electron-beam facility was available and we were unable to deliver the IMN irradiation as planned to 33 patients. The remaining 67 patients (32 treated before and 35 treated after this period) received IMN irradiation. Patients with receptor-positive tumors received tamoxifen for 5 years. RESULTS At a median follow-up of 77 months for all of the patients, disease-free survival (DFS) was significantly prolonged in patients receiving IMN radiation compared to those without IMN radiation (73% v 52%; P =.02). A trend was seen for overall survival (OS; 78% v 64%; P =.08). Cox regression multivariate analysis found IMN radiotherapy to be significant both for DFS and OS. Estrogen receptor positivity was also significant for DFS. There was no treatment related mortality. CONCLUSION In patients with high-risk stage II to III breast cancer, the inclusion of the IMN in the radiotherapy field was associated with a statistically significant increase in DFS and a borderline increase in OS.
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Affiliation(s)
- Salomon M Stemmer
- Bone Marrow Transplant Service, Department of Oncology, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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Fortin A, Dagnault A, Larochelle M, Vu TTT. Impact of locoregional radiotherapy in node-positive patients treated by breast-conservative treatment. Int J Radiat Oncol Biol Phys 2003; 56:1013-22. [PMID: 12829137 DOI: 10.1016/s0360-3016(03)00202-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE The aim of this study is to evaluate the impact of locoregional radiation in node-positive patients treated by tumorectomy and radiation therapy. METHODS A retrospective study including all our 1368 T1-2 node-positive patients was conducted. Conservative surgery was followed by breast irradiation. Axillary and supraclavicular irradiation was left to the discretion of the treating radiation oncologist. RESULTS In the group receiving locoregional radiation (472 patients), the 10-year regional control was 97% vs. 91% for the group receiving radiation to the breast only (896 patients) (p = 0.004). In a Cox model analysis, locoregional radiation is associated with a better regional control rate (hazard ratio: 0.27; 95% confidence interval: 0.13-0.54, p = 0.0001). Locoregional radiotherapy is associated with a better rate of locoregional control (hazard ratio: 0.56; 95% confidence interval: 0.38-0.8, p = 0.002). In particular, for the N>3 group, the substantial 10-year locoregional failure rate (26% with breast irradiation only) is cut by 50%. Locoregional radiotherapy, however, is not associated with a lower rate of distant metastases. CONCLUSION Locoregional radiation decreases the rate of locoregional failure by nearly 50%. Locoregional radiotherapy should be considered for node-positive patients, especially if they have more than 3 positive nodes.
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Affiliation(s)
- André Fortin
- Department of Radiation Oncology, l'Hotel-Dieu de Québec Hospital, Laval University, Quebec City, Quebec, Canada.
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Abstract
In 1999, the European Organisation for Research and Treatment of Cancer (EORTC), being a European pioneer in the field of cancer research as well as in quality assurance (QA), launched an Emmanuel van der Schueren fellowship for QA in radiotherapy. In this paper, the work that has been done during the first E. van der Schueren fellowship is reported, focusing on four phase III EORTC clinical trials: 22921 for rectal cancer, 22961 and 22991 for prostate cancer and 22922 for breast cancer. A historical review of the QA programme of the EORTC Radiotherapy group during the past 20 years is included.
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Affiliation(s)
- V E Kouloulias
- European Organisation for Research and Treatment of Cancer (EORTC), Data Center, Avenue Mounier 83, B-1200, Brussels, Belgium.
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Whelan T. Treatment of the internal mammary nodes in early breast cancer: back to the future. Clin Oncol (R Coll Radiol) 2003; 15:14-6. [PMID: 12602549 DOI: 10.1053/clon.2002.0147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Remouchamps VM, Vicini FA, Sharpe MB, Kestin LL, Martinez AA, Wong JW. Significant reductions in heart and lung doses using deep inspiration breath hold with active breathing control and intensity-modulated radiation therapy for patients treated with locoregional breast irradiation. Int J Radiat Oncol Biol Phys 2003; 55:392-406. [PMID: 12527053 DOI: 10.1016/s0360-3016(02)04143-3] [Citation(s) in RCA: 292] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE To evaluate the heart and lung sparing effects of moderate deep inspiration breath hold (mDIBH) achieved using an active breathing control (ABC) device, compared with free breathing (FB) during treatment with deep tangents fields (DT) for locoregional (LR) irradiation of breast cancer patients, including the internal mammary (IM) nodes (IMNs). To compare the DT-mDIBH technique to other standard techniques and to evaluate the dosimetric effect of intensity-modulated radiation therapy (IMRT). METHODS AND MATERIALS Fifteen patients (9 left-sided and 6 right-sided lesions) with Stages 0-III breast cancer underwent standard FB and ABC computed tomographic (CT) scans in the treatment position. A dosimetric planning study was performed. In FB, the 9 left-sided patients were planned with a 5-field technique where electron fields covering the IM region were matched to shallow tangents using wedges (South West Oncology Group [SWOG] protocol S9927 technique A). This method was compared with a 3-field DT technique covering the breast and the IMNs (SWOG S9927 technique B). Compensation with IMRT was then compared with wedges for each technique. For the 15 total patients, dosimetric planning using DT with IMRT was then reoptimized on the mDIBH CT data set for comparison. Dose-volume histograms for the clinical target volume (CTV) (including the IMNs), planning target volume (PTV), ipsilateral and contralateral breast, and organs at risk (OAR) were analyzed. In addition, normal tissue complication probabilities (NTCP) for lung and heart, mean lung doses, and the number of monitor units (MUs) for a 1.8 Gy fraction were compared. RESULTS For the 9 left-sided patients, the mean percentage of heart receiving more than 30 Gy (heart V30) was lower with the 5-field wedged technique than with the DT wedged technique (6.8% and 19.1%, respectively, p < 0.004). For the DT technique, the replacement of wedges with IMRT slightly diminished the mean heart V30 to 16.3% (p < 0.51). The introduction of mDIBH to the DT-IMRT technique reduced the heart V30 by 81% to a mean of 3.1% (p < 0.0004). Compared with 5-field IMRT, DT-IMRT with mDIBH reduced the heart V30 for 6 of the 9 patients, entirely avoiding heart irradiation in 2 of these 6 patients. For DT-IMRT, mDIBH reduced the mean lung dose and NTCP to levels obtained with the 5-field IMRT technique. For the 15 patients planned with DT-IMRT in FB, the use of mDIBH reduced the mean percentage of both lungs receiving more than 20 Gy from 20.4% to 15.2% (p < 0.00007). With DT-IMRT, more than 5% of the contralateral breast received more than 10 Gy for 6 of the 9 left-sided patients in FB, 3 of those 9 patients in mDIBH, and only 1 of those 9 patients planned with 5 fields. The mean % of the PTV receiving more than 55 Gy (110% of the prescribed dose) was 36.4% for 5-field wedges, 33.4% for 5-field IMRT, 28.7% for DT-wedges, 12.5% for DT-IMRT, and 18.4% for DT-IMRT mDIBH. The CTV remained covered by the 95% isodose in all the DT plans but one (99.1% of the volume covered). DT-wedges required more MUs than DT-IMRT (mean of 645 and 416, respectively, p < 0.00004). CONCLUSION mDIBH significantly reduces heart and lung doses when DT are used for LR breast irradiation including the IMNs. Compared with shallow tangents matched with electrons, DT with mDIBH reduces the heart dose (in most patients) and results in comparable lung toxicity parameters, but may increase the dose to the contralateral breast. IMRT improves dose homogeneity, slightly reduces the dose to the heart, and diminishes the number of MUs required.
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Affiliation(s)
- Vincent M Remouchamps
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA
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Lievens Y, Van den Bogaert W. Internal mammary and medial supraclavicular lymph node irradiation: the thin line between advantages and side effects. Radiother Oncol 2002; 65:75-7. [PMID: 12443802 DOI: 10.1016/s0167-8140(02)00285-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Holli K, Pitkänen M, Järvenpää R, Rajala J, Lahtela S, Hyödynmaa S, Ojala A. Early skin and lung reactions in breast cancer patients after radiotherapy: prospective study. Radiother Oncol 2002; 64:163-9. [PMID: 12242126 DOI: 10.1016/s0167-8140(02)00168-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE The association between early radiological lung reactions consequent upon radiotherapy and patients' symptoms is not well established. This prospective study examined the association between symptoms experienced by the patient, clinical findings observed by the physician and reactions visible in chest X-ray as interpreted by a radiologist, as well as the association between skin or breast symptoms and lung symptoms induced by radiotherapy after different methods of surgery. METHODS Altogether 207 consecutive breast cancer patients entered the trial between 1st October 1997 and 31st December 1998. Chest X-rays were taken at entry and 3, 6 and 12 months after radiotherapy. The frequency and intensity of symptoms as well as clinical and chest X-ray findings were assessed over time. RESULTS Skin and breast symptoms were common after radiotherapy but seldom severe (9%). Lung reactions were seen in chest X-ray in 47% of patients in re-evaluation by a radiologist at 3 months. The frequency of lung or skin symptoms did not correlate with chest X-ray findings, but there was a significant correlation between skin and lung symptoms. Radiotherapy after conservative surgery for node-positive breast cancer caused lung reactions seen in chest X-ray more often than after mastectomy when using other techniques. The reactions were most common at the 6 month evaluation (P=0.01). Concomitant adjuvant chemo- or endocrine therapy did not significantly increase the incidence of lung reactions. CONCLUSIONS Skin, breast and lung symptoms were frequent after radiotherapy, but there was no real association between lung or skin symptoms and chest X-ray findings. The only correlation noted was between skin or breast symptoms and lung symptoms experienced by patients. Radiotherapy after conservative surgery was more frequently linked to chest X-ray findings than radiotherapy after mastectomy. We conclude that routine chest X-ray after radiotherapy gives no more clinically relevant information than the symptoms of the patient and we do not recommend routine chest X-rays for that reason.
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Affiliation(s)
- Kaija Holli
- Department of Palliative Medicine, Tampere University Hospital and University of Tampere, Tampere, Finland
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Fogliata A, Bolsi A, Cozzi L. Critical appraisal of treatment techniques based on conventional photon beams, intensity modulated photon beams and proton beams for therapy of intact breast. Radiother Oncol 2002; 62:137-45. [PMID: 11937240 DOI: 10.1016/s0167-8140(01)00476-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To analyse different treatment techniques with conventional photon beams, intensity modulated photon beams, and proton beams for intact breast irradiation for patients in whom conventional irradiation would cause potentially dangerous lung irradiation. MATERIALS AND METHODS Five breast cancer patients with highly concave breast tissue volume around the lung were considered at planning level in order to assess the suitability of different irradiation techniques. Three-dimensional dose distributions for conventional two-field tangential photon treatment, two-field intensity modulated radiotherapy (IMRT), three-field non-IMRT, three-field IMRT, and single-field proton treatment were investigated, aiming at assessing the possibility to reduce lung irradiation below risk levels. Analysis of dose-volume histograms and related physical and biological parameters (significant minimum, maximum and mean doses, conformity indexes and equivalent uniform dose (EUD)) for planned target volume (PTV) and lung was carried out. Dose plans were compared with the conventional two-field tangential photon technique. RESULTS PTV coverage was comparable for non-IMRT and IMRT techniques (EUD from 47.1 to 49.4 Gy), and improved with single-field proton treatment (EUD=49.8 Gy). Lung irradiation was reduced, in terms of mean dose, with three-field (9.5 Gy) and proton technique (3.5 Gy), with respect to the conventional two-field treatment (12.9 Gy); also a reduction of the lung volume irradiated at high doses was observed. Better results could be achieved with protons. In addition, cardiac irradiation was also reduced with those techniques. CONCLUSIONS Geometrically difficult breast cancer patients could be irradiated with a three-field non-IMRT technique thus reducing the dose to the lung which is proposed as standard for this category of patients. Intensity modulated techniques were only marginally more successful than the corresponding non-IMRT treatments, while protons offer excellent results.
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Affiliation(s)
- Antonella Fogliata
- Radiation Oncology Department, Medical Physics Unit, Oncology Institute of Southern Switzerland, c/o Ospedale S. Giovanni, 6504 Bellinzona, Switzerland
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Sartor CI. Postmastectomy radiotherapy in women with breast cancer metastatic to one to three axillary lymph nodes. Curr Oncol Rep 2001; 3:497-505. [PMID: 11595118 DOI: 10.1007/s11912-001-0071-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The influence of postmastectomy radiotherapy on survival has long been debated. Early randomized trials established a clear role for adjuvant postmastectomy chest wall radiotherapy (PMCWRT) in reducing locoregional recurrence (LRR), and PMCWRT became standard therapy for patients at high risk of LRR: those with T3 or T4 tumors and four or more involved lymph nodes. However, without effective systemic therapy, distant metastases limited any effect of improved local control on overall outcome, and radiotherapy showed no benefit in survival. In fact, early meta-analyses showed a negative impact of radiotherapy on survival. As data and techniques matured, a favorable influence of PMCWRT on breast cancer-specific mortality emerged but was offset by a radiotherapy-related increase in vascular mortality. Improvements in radiotherapy delivery to increase efficacy and reduce toxicity, restriction of PMCWRT to patients at intermediate or high risk of LRR after mastectomy, and improved distant control of disease with systemic therapy are expected to bring the greatest likelihood of a survival advantage from locoregional control. Three randomized trials with sufficient follow-up meet these criteria. All demonstrate significant improvement in overall survival with PMCWRT. However, the trials were not designed to specifically address the benefit of PMCWRT in patients at intermediate risk of LRR (those with T1 or T2 tumors and one to three involved lymph nodes). These findings have been discussed in a host of publications and conferences in light of historical negative results. This review focuses on the recent data on PMCWRT in patients with one to three involved nodes.
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Affiliation(s)
- C I Sartor
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA.
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Lievens Y, Poortmans P, Van den Bogaert W. A glance on quality assurance in EORTC study 22922 evaluating techniques for internal mammary and medial supraclavicular lymph node chain irradiation in breast cancer. Radiother Oncol 2001; 60:257-65. [PMID: 11514005 DOI: 10.1016/s0167-8140(01)00351-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the irradiation techniques used for the irradiation of the internal mammary and medial supraclavicular lymph node chain (IM-MS) in the EORTC 22922 study, which evaluates its impact on survival in stage I-III breast cancer patients with axillary node invasion and/or central or medial location of the primary tumour. MATERIALS AND METHODS The analysis was performed based on the dummy run data of the Quality Assurance Programme of the study. A standard irradiation technique was proposed within the study protocol, and the use of other treatment set-up techniques was allowed. RESULTS By March 2000, 39 centres from 12 different countries had participated in the study; 32 of these had already fulfilled the dummy run procedure. No centres had to be excluded from the study. Seventy-eight percent of the centres are using the standard irradiation technique, 64% of these with minor variations. Twenty-two percent of the centres developed an alternative irradiation technique. The remarks to the centres using the standard set-up were most often related to the junction problem and the possible under- or overdosage in the target volumes. The remarks to the centres with alternative techniques most often concerned the possible enhanced dose to the lungs and the heart. CONCLUSION In a multi-centre trial an easy irradiation technique applicable in a large number of centres should be provided. A quality assurance programme allows early detection of possible problems with treatment planning and delivery. The analysis of the dummy run data showed that if the recommendations of the Quality Assurance Committee are applied, both standard and alternative IM-MS irradiation techniques produce acceptable dose distributions.
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Affiliation(s)
- Y Lievens
- Radiotherapy Department, University Hospital, Herestraat 49, 3000 Leuven, Belgium
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Poortmans PM, Venselaar JL, Struikmans H, Hurkmans CW, Davis JB, Huyskens D, van Tienhoven G, Vlaun V, Lagendijk JJ, Mijnheer BJ, De Winter KA, Van der Hulst MH, Van den Bogaert WF. The potential impact of treatment variations on the results of radiotherapy of the internal mammary lymph node chain: a quality-assurance report on the dummy run of EORTC Phase III randomized trial 22922/10925 in Stage I--III breast cancer(1). Int J Radiat Oncol Biol Phys 2001; 49:1399-408. [PMID: 11286848 DOI: 10.1016/s0360-3016(00)01549-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To present the results of the dummy run of the European Organization for Research and Treatment of Cancer (EORTC) trial investigating the role of adjuvant internal mammary and medial supraclavicular (IM-MS) irradiation in Stage I--III breast cancer. METHODS AND MATERIALS All participating institutions were asked to produce a treatment plan without (Arm 1) and with (Arm 2) simultaneous IM-MS irradiation of 1 patient after mastectomy and of 1 patient after lumpectomy. Thirty-two dummy runs have been evaluated for compliance to protocol guidelines, with respect to treatment technique and dose prescription. RESULTS A number of more or less important deviations in treatment setup and prescription have been found. The dose in the IM-MS region deviated significantly from the prescribed dose in 10% of the cases for Arm 1, and in 21% for Arm 2. Assuming a true 5% 10-year survival benefit from optimal IM-MS irradiation, an increase of only 3.8% will be found due to this suboptimal dose distribution. CONCLUSION In the dummy run, a number of potential systematic protocol deviations that might lead to false-negative results were detected. By providing recommendations to the participating institutions, we expect to improve the interinstitutional consistency and to promote a high quality irradiation in all institutions participating in the trial.
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Affiliation(s)
- P M Poortmans
- Department of Radiotherapy, Dr. Bernard Verbeeten Instituut, Tilburg, The Netherlands.
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