• Breast neoplasms
• Conformal
• Intensity-modulated
• Quality of life
• Radiotherapy
• Skin diseases

• Humans
• Breast Neoplasms/radiotherapy
• Breast Neoplasms/complications
• Female
• Cancer Survivors
• Quality of Life
• Radiotherapy, Intensity-Modulated/adverse effects
• Radiotherapy, Intensity-Modulated/methods
• Radiation Injuries/etiology
• Radiation Injuries/epidemiology
• Skin/radiation effects
• Skin/pathology

• APP1194051 Australian National Health and Medical Research Council

• Local regional relapse
• Post-mastectomy radiotherapy
• Target volume

• Humans
• Breast Neoplasms/radiotherapy
• Breast Neoplasms/pathology
• Breast Neoplasms/surgery
• Female
• Mastectomy
• Mammaplasty/methods
• Middle Aged
• Neoplasm Recurrence, Local
• Retrospective Studies
• Adult
• Aged
• Radiotherapy, Adjuvant
• Radiotherapy Dosage

• Università degli Studi di Firenze

• Humans
• Female
• Retrospective Studies
• Mastectomy
• Middle Aged
• Breast Neoplasms/radiotherapy
• Breast Neoplasms/surgery
• Breast Implants
• Breast Implantation/methods
• Breast Implantation/instrumentation
• Breast Implantation/adverse effects
• Radiotherapy, Adjuvant/adverse effects
• Radiotherapy, Adjuvant/methods
• Adult
• Treatment Outcome
• Postoperative Complications/etiology
• Postoperative Complications/epidemiology
• Postoperative Complications/prevention & control
• Tissue Expansion Devices
• Radiotherapy, Intensity-Modulated/adverse effects
• Radiotherapy, Intensity-Modulated/methods
• Aged
• Mammaplasty/methods
• Mammaplasty/adverse effects
• Tissue Expansion/methods
• Tissue Expansion/instrumentation
• Tissue Expansion/adverse effects

• Ethos
• Halcyon
• breast IMRT

• Humans
• Radiotherapy Planning, Computer-Assisted/methods
• Radiotherapy, Intensity-Modulated/methods
• Radiotherapy Dosage
• Female
• Thoracic Wall/radiation effects
• Organs at Risk/radiation effects
• Breast Neoplasms/radiotherapy
• Lymph Nodes/radiation effects

• Automation in radiation therapy
• Breast cancer
• Deep learning
• Treatment planning

• Breast cancer
• Dose Hypofractionation
• Predectifs factors
• Regional lymph node hypofractionated radiation
• Side effects

• Humans
• Female
• Breast Neoplasms/radiotherapy
• Radiotherapy Dosage
• Radiotherapy Planning, Computer-Assisted/methods
• Esophageal Neoplasms/radiotherapy
• Radiotherapy, Intensity-Modulated/methods

• Acute radiation dermatitis
• breast cancer
• factor analysis
• radiotherapy

To validate the BCCT.core software, the present analysis compares the esthetics assessment by the software in relation to patients’ and physicians’ rating in breast cancer patients after surgery and adjuvant radiotherapy. Agreement rates of the different assessments and their correlation with breast asymmetry indices were evaluated. The assessments of the software and the physicians were significantly correlated with all asymmetry indices, while for patients’ self-assessment, this general correlation was first seen after 2 years. Only a slight agreement between the BCCT.core software and the physicians’ or patients’ assessment was seen, while a moderate and substantial agreement was detected between the physicians’ and the patients’ assessments. The BCCT.core software is a reliable tool to measure asymmetries, but may not sufficiently evaluate the esthetic outcome as perceived by patients. It may be more appropriate for a long-term follow-up, when symmetry seems to increase in importance.

The present analysis compares the esthetics assessment by the BCCT.core software in relation to patients’ and physicians’ ratings, based on the IMRT-MC2 trial. Within this trial, breast cancer patients received breast-conserving surgery (BCS) and adjuvant radiotherapy. At the baseline, 6 weeks, and 2 years after radiotherapy, photos of the breasts were assessed by the software and patients’ and physicians’ assessments were performed. Agreement rates of the assessments and their correlation with breast asymmetry indices were evaluated. The assessments of the software and the physicians were significantly correlated with asymmetry indices. Before and 6 weeks after radiotherapy, the patients’ self-assessment was only correlated with the lower breast contour (LBC) and upward nipple retraction (UNR), while after 2 years, there was also a correlation with other indices. Only a slight agreement between the BCCT.core software and the physicians’ or patients’ assessment was seen, while a moderate and substantial agreement was detected between the physicians’ and the patients’ assessment after 6 weeks and 2 years, respectively. The BCCT.core software is a reliable tool to measure asymmetries, but may not sufficiently evaluate the esthetic outcome as perceived by patients. It may be more appropriate for a long-term follow-up, when symmetry appears to increase in importance.

• BCCT.core software
• adjuvant whole-breast radiotherapy
• breast cancer
• cosmesis
• esthetic assessment

• Breast Neoplasms/etiology
• Breast Neoplasms/radiotherapy
• Female
• Humans
• Prospective Studies
• Radiotherapy Planning, Computer-Assisted/methods
• Radiotherapy, Conformal/adverse effects
• Radiotherapy, Conformal/methods
• Radiotherapy, Intensity-Modulated/adverse effects
• Radiotherapy, Intensity-Modulated/methods

Acute radiation dermatitis (ARD) is the most common acute response after adjuvant radiotherapy in breast cancer patients and negatively affects patients’ quality of life. Some studies have reported several risk factors that can predict breast cancer patients who are at a high risk of ARD. This study aimed to identify patient- and treatment-related risk factors associated with ARD.

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and WanFang literature databases were searched for studies exploring the risk factors in breast cancer patients. The pooled effect sizes, relative risks (RRs), and 95% CIs were calculated using the random-effects model. Potential heterogeneity and sensitivity analyses by study design, ARD evaluation scale, and regions were also performed.

A total of 38 studies composed of 15,623 breast cancer patients were included in the analysis. Of the seven available patient-related risk factors, four factors were significantly associated with ARD: body mass index (BMI) ≥25 kg/m² (RR = 1.11, 95% CI = 1.06–1.16, I² = 57.1%), large breast volume (RR = 1.02, 95% CI = 1.01–1.03, I² = 93.2%), smoking habits (RR = 1.70, 95% CI = 1.24–2.34, I² = 50.7%), and diabetes (RR = 2.24, 95% CI = 1.53–3.27, I² = 0%). Of the seven treatment-related risk factors, we found that hypofractionated radiotherapy reduced the risk of ARD in patients with breast cancer compared with that in conventional fractionated radiotherapy (RR = 0.28, 95% CI = 0.19–0.43, I² = 84.5%). Sequential boost and bolus use was significantly associated with ARD (boost, RR = 1.91, 95% CI = 1.34–2.72, I² = 92.5%; bolus, RR = 1.94, 95% CI = 1.82–4.76, I² = 23.8%). However, chemotherapy regimen (RR = 1.17, 95% CI = 0.95–1.45, I² = 57.2%), hormone therapy (RR = 1.35, 95% CI = 0.94–1.93, I² = 77.1%), trastuzumab therapy (RR = 1.56, 95% CI = 0.18–1.76, I² = 91.9%), and nodal irradiation (RR = 1.57, 95% CI = 0.98–2.53, I² = 72.5%) were not correlated with ARD. Sensitivity analysis results showed that BMI was consistently associated with ARD, while smoking, breast volume, and boost administration were associated with ARD depending on study design, country of study, and toxicity evaluation scale used. Hypofractionation was consistently shown as protective. The differences between study design, toxicity evaluation scale, and regions might explain a little of the sources of heterogeneity.

The results of this systematic review and meta-analysis indicated that BMI ≥ 25 kg/m² was a significant predictor of ARD and that hypofractionation was consistently protective. Depending on country of study, study design, and toxicity scale used, breast volume, smoking habit, diabetes, and sequential boost and bolus use were also predictive of ARD.

• acute radiation dermatitis
• breast cancer
• meta-analysis
• radiotherapy
• risk factor

The primary objective is to examine patient self‐assessment of breast pain and cosmesis between three‐dimensional (3D‐CRT) versus intensity‐modulated radiotherapy (IMRT). The secondary objective is to evaluate any relationship of treatment planning conformality of both cohorts to patient‐assessed pain. Assessments were performed at interim 12, 24, 36, and 48 months with a final 5‐year assessment.

In total, 656 patients (3D‐CRT n = 328; IMRT n = 328) were randomly assigned to either IMRT or 3D‐CRT accelerated partial breast radiotherapy to 38.5 Gy in 10 BID 3.85 Gy fractions.

Median follow‐up was 3 years. Multivariate analysis showed that pain severity significantly decreased from baseline to the 12‐month follow‐up visit (<0.001 for both 3D‐CRT and IMRT) in each cohort. There was significantly less pain at 2 (p = 0.002) and 3 years (0.045) in the IMRT arm versus the 3D‐CRT arm when compared to the baseline pain level. There was no difference in patient‐assessed cosmesis at any follow‐up point; however, although MD‐assessed cosmesis showed no difference from years 1 to 4, there was significantly better cosmesis for 3D‐CRT versus IMRT (p = 0.047) at 5 years. There was a significant correlation between a maximum pain score and an increase in the CI₁₀₀ (indicating less conformity) in the IMRT cohort (p < 0.01) and in the IMRT subgroup when the CI₁₀₀ was ≤0.37 cohort arm (p = 0.01).

In the analysis of our primary objective we found that at 2 years, IMRT resulted in more interval improvement in breast pain after baseline when compared to patients treated with 3D‐CRT planning. As seen in our secondary analysis, this may be due to the ability of IMRT to achieve higher conformality (as evidenced by lower CI values) resulting in less fibrosis. There were no differences in patient‐assessed cosmesis or MD‐assessed cosmesis for years 1–4; however, physician‐assessed 5‐year cosmesis was better with 3D‐CRT.

• accelerated partial breast
• breast cancer
• radiotherapy

Published treatment technique comparisons for postoperative left-sided whole breast irradiation (WBI) with deep-inspiration breath-hold (DIBH) are scarce, small, and inconclusive. In this study, fully automated multi-criterial plan optimization, generating a single high-quality, Pareto-optimal plan per patient and treatment technique, was used to compare for a large patient cohort 1) intensity modulated radiotherapy (IMRT) with two tangential fields and 2) volumetric modulated arc therapy (VMAT) with two small tangential subarcs.

Forty-eight randomly selected patients recently treated with DIBH and 16 × 2.66 Gy were included. The optimizer was configured for the clinical planning protocol. Comparisons between IMRT and VMAT included dosimetric plan parameters, estimated excess relative risks (ERR) for toxicities, delivery times, MUs, and deliverability accuracy at a linac.

The automatically generated IMRT and VMAT plans applied in this study were similar or higher in quality than the manually generated clinical plans. For equal PTVin V95% (98.4 ± 0.9%), VMAT had significant advantages compared to IMRT regarding breast dose homogeneity and doses in heart and ipsilateral lung, at the cost of some minor deteriorations for contralateral breast (few cases with larger deteriorations) and lung. Conformality improved from 1.38 to 1.18 (p < 0.001). With VMAT, ERR for major coronary events and ipsilateral lung tumors were reduced by 3% (range: −1–12%) and 16% (range: −3–38%), respectively. MUs and delivery times were higher for VMAT. There were no statistical differences in γ passing rates.

For WBI in conservative therapy of left-sided breast patients treated with DIBH, VMAT with two tangential subarcs was generally dosimetrically superior to IMRT with two tangential static fields. Results need confirmation by robustness analyses.

• Autoplanning
• Breast cancer
• Deep inspiration breath-hold
• Modulated radiation therapy
• Partial arcs volumetric modulated arc therapy
• Tangent-based intensity

The dose perturbation effect of immobilization devices is often overlooked in intensity-modulated radiation therapy (IMRT) for breast cancer (BC). This retrospective study assessed the dosimetric effects of supine immobilization devices on the skin using a commercial treatment planning system.

Forty women with BC were divided into four groups according to the type of primary surgery: groups A and B included patients with left and right BC, respectively, who received 50 Gy radiotherapy in 25 fractions after radical mastectomy, while groups C and D included patients with left and right BC, respectively, who received breast-conservation surgery (BCS) and 40.05 Gy in 15 fractions as well as a tumor bed simultaneous integrated boost to 45 Gy. A 0.2-cm thick skin contour and two sets of body contours were outlined for each patient. Dose calculations were conducted for the two sets of contours using the same plan. The dose differences were assessed by comparing the dose-volume histogram parameter results and by plan subtraction.

The supine immobilization devices for BC resulted in significantly increased skin doses, which may ultimately lead to skin toxicity. The mean dose increased by approximately 0.5 and 0.45 Gy in groups A and B after radical mastectomy and by 2.7 and 3.25 Gy in groups C and D after BCS; in groups A–D, the percentages of total normal skin volume receiving equal to or greater than 5 Gy (V₅) increased by 0.54, 1.15, 2.67, and 1.94%, respectively, while the V₁₀ increased by 1.27, 1.83, 1.36, and 2.88%; the V₂₀ by 0.85, 1.87, 2.76, and 4.86%; the V₃₀ by 1.3, 1.24, 10.58, and 11.91%; and the V₄₀ by 1.29, 0.65, 10, and 10.51%. The dose encompassing the planning target volume and other organs at risk, showed little distinction between IMRT plans without and with consideration of immobilization devices.

The supine immobilization devices significantly increased the dose to the skin, especially for patients with BCS. Thus, immobilization devices should be included in the external contour to account for dose attenuation and skin dose increment.

This study does not report on interventions in human health care.

• Breast cancer
• Intensity-modulated radiation therapy
• Skin dose
• Supine immobilization devices

Breast edema can arise from different etiologies; however, it is mostly seen after breast conserving surgery and/or radiotherapy. Combining breast conserving surgery and radiotherapy can cause damage to the lymphatic system and reactions to surrounding tissues, which can lead to breast edema; hereby, the breast size can increase by more than one cup size. Swelling of the breast is not the only criterion associated with breast edema. Other common criteria found in literature are peau d’orange, heaviness of the breast, skin thickening, breast pain, redness of the skin, hyperpigmented skin pores and a positive pitting sign. Despite the benefits of breast conserving surgery, breast edema can be uncomfortable, and can negatively influence quality of life in suffering patients. In contrast to lymphedema of the arm, which is well known in clinical practice and in research, breast edema is often underestimated and far less explored in literature. Currently, many aspects still need to be reviewed.

This masterclass aims at providing the state of the art of breast edema for all health care workers and researchers involved in the treatment and monitoring of breast cancer patients. It includes current and future perspectives on its diagnosis, longitudinal course and treatment. Furthermore, recommendations for clinical practice and future research are discussed.

It is recommended to closely monitor those patients in whom breast edema symptoms do not decline within 6 months after termination of radiotherapy and provide them with the appropriate therapy. Since evidence concerning the treatment of breast edema is currently lacking, we recommend the complex decongestive therapy (CDT) to the utmost extent, by analogy with the lymphedema treatment of the extremities. This treatment involves skin care, exercise therapy and compression. Additionally, all patients should be informed about the normal course of breast edema development.

A consensus should be reached among clinicians and researchers concerning the definition, assessment methods and best treatment of breast edema. Furthermore, high quality studies are necessary to prove the effectiveness of the CDT for breast edema.

The online version contains supplementary material available at 10.1186/s40945-021-00103-4.

• Breast edema
• Breast neoplasms
• Diagnosis
• Management

ORCID: 0000–0001-6019–7309. In the treatment of breast cancer, intensity-modulated radiation therapy (IMRT) reportedly reduces the high-dose irradiation of at-risk organs and decreases the frequency of adverse events (AEs). Comparisons with conventional radiotherapy have shown that IMRT is associated with lower frequencies of acute and late-onset AEs. Here, we extended a prospective, observational, single-center study of the safety of IMRT to a second investigating center. Patients scheduled for adjuvant IMRT after partial or total mastectomy were given a dose of 50 Gy (25 fractions of 2 Gy over 5 weeks), with a simultaneous integrated boost in patients having undergone conservative surgery. 300 patients were included in the study, and 288 were analyzed. The median follow-up period was 2.1 years. The 2-year disease-free survival rate [95% CI] was 93.4% [89.2–96.0%]. Most AEs were mild. The most common AEs were skin-related—mainly radiodermatitis [in 266 patients (92.4%)] and hyperpigmentation (in 178 (61.8%)). 35% and 6% of the patients presented with grade 2 acute skin and esophageal toxicity, respectively. Only 4 patients presented with a grade 3 event (radiodermatitis). Smoking (odds ratio) [95% CI] = 2.10 [1.14–3.87]; p = 0.017), no prior chemotherapy (0.52 [0.27–0.98]; p = 0.044), and D98% for subclavicular skin (1.030 [1.001–1.061]; p = 0.045) were associated with grade ≥ 2 acute AEs. In a univariate analysis, the mean dose, (p < 0.0001), D2% (p < 0.0001), D50% (p = 0.037), D95% (p = 0.0005), D98% (p = 0.0007), V30Gy (p < 0.0001), and V45Gy (p = 0.0001) were significantly associated with grade ≥ 1 acute esophageal AEs. In a multivariate analysis, D95% for the skin (p < 0.001), D98% for the subclavicular skin and low D95% for the internal mammary lymph nodes were associated with grade ≥ 1 medium-term AEs. The safety profile of adjuvant IMRT after partial or total mastectomy is influenced by dosimetric parameters.

Trial registration: ClinicalTrials.gov NCT02281149.

• Normal tissue toxicity
• breast cancer
• conventional radiotherapy
• risk factors

• Adult
• Aged
• Aged, 80 and over
• Antineoplastic Agents/administration & dosage
• Breast Neoplasms/pathology
• Breast Neoplasms/therapy
• Combined Modality Therapy
• Dose Fractionation, Radiation
• Female
• Follow-Up Studies
• Humans
• Letrozole/administration & dosage
• Mastectomy/methods
• Middle Aged
• Prognosis
• Prospective Studies
• Radiation Injuries/drug therapy
• Radiation Injuries/etiology
• Radiation Injuries/pathology
• Radiodermatitis/drug therapy
• Radiodermatitis/etiology
• Radiodermatitis/pathology
• Radiotherapy, Adjuvant/adverse effects

• Adult
• Aged
• Aged, 80 and over
• Breast/radiation effects
• Breast Neoplasms/mortality
• Breast Neoplasms/radiotherapy
• Breast Neoplasms/surgery
• Female
• Follow-Up Studies
• Heart/radiation effects
• Humans
• Lung/radiation effects
• Mastectomy, Segmental
• Middle Aged
• Organs at Risk/radiation effects
• Prospective Studies
• Radiotherapy, Adjuvant
• Radiotherapy, Conformal/methods
• Radiotherapy, Intensity-Modulated/methods
• Survival Rate
• Time Factors
• Treatment Outcome

To present the 7-year results of accelerated partial breast irradiation (APBI) using three-dimensional conformal (3D-CRT) and image-guided intensity-modulated radiotherapy (IG-IMRT) following breast-conserving surgery (BCS).

Between 2006 and 2014, 104 patients were treated with APBI given by means of 3D-CRT using 3–5 non-coplanar, isocentric wedged fields, or IG-IMRT using kV-CBCT. The total dose of APBI was 36.9 Gy (9 × 4.1 Gy) using twice-a-day fractionation. Survival results, side effects and cosmetic results were assessed.

At a median follow-up of 90 months three (2.9%) local recurrences, one (0.9%) regional recurrence and two (1.9%) distant metastases were observed. The 7-year local (LRFS), recurrence free survival was 98.9%. The 7-year disease-free (DFS), metastases free (MFS) and overall survival (OS) was 94.8%, 97.9% and 94.8%, respectively. Late side effects included G1 skin toxicity in 15 (14.4%), G1, G2, and G3 fibrosis in 26 (25%), 3 (2.9%) and 1 (0.9%) patients respectively. Asymptomatic (G1) fat necrosis occurred in 10 (9.6%) patients. No ≥ G2 or higher late side effects occurred with IMRT. The rate of excellent/good and fair/poor cosmetic results was 93.2% and 6.8%, respectively.

7-year results of APBI with 3D-CRT and IG-IMRT are encouraging. Toxicity profile and local tumor control are comparable to other series using multicatheter interstitial brachytherapy. Therefore, these external beam APBI techniques are valid alternatives to whole breast irradiation and brachytherapy based APBI.

•

Phase II APBI trial using 3D-CRT or IG-IMRT.

• 3-Dimensional conformal radiotherapy
• Breast cancer
• Image-guided intensity-modulated radiotherapy
• Partial breast irradiation
• Phase II trial

• Adult
• Aged
• Breast Neoplasms/mortality
• Breast Neoplasms/therapy
• Dose Fractionation, Radiation
• Feasibility Studies
• Female
• Follow-Up Studies
• Humans
• Mastectomy, Segmental
• Middle Aged
• Neoplasm Recurrence, Local/epidemiology
• Postoperative Period
• Radiation Injuries/etiology
• Radiation Injuries/mortality
• Radiotherapy Planning, Computer-Assisted/methods
• Radiotherapy Planning, Computer-Assisted/mortality
• Radiotherapy, Conformal/methods
• Radiotherapy, Conformal/mortality
• Radiotherapy, Intensity-Modulated/methods
• Radiotherapy, Intensity-Modulated/mortality
• Survival Rate
• Treatment Outcome

During radiotherapy (RT) procedure of breast cancer, portions of the heart and lung will receive some radiation dose, which may result in acute and late toxicities. In the current study, we report the experience of our single institution with organs at risk (OARs)–sparing RT with deep inspiration breath hold (DIBH) using an Optical Surface Management System (OSMS) and compare the dosimetric parameters with that of free breathing (FB).

Forty-eight cases diagnosed as early stage left-sided breast cancer scheduled for postoperative RT were enrolled. The OSMS was used to monitor the breathing magnitude and track the real-time respiratory status, which can control a stable lung and heart volume during RT delivery under DIBH. We did the dosimetric analysis of the heart, left anterior descending (LAD) coronary artery, lungs, and contralateral breast under FB and DIBH plans.

Compared with FB–volumetric-modulated arc therapy (FB-VMAT), DIBH-VMAT resulted in significantly changed volumes to the heart and lungs receiving irradiation dose. The average mean heart dose and average D2%, V₅, and V₁₀ showed significant differences between the DIBH and FB techniques. For the LAD coronary artery, we found significantly reduced average mean dose, D2%, and V₁₀ with DIBH. Similar results were also found in the lungs and contralateral breast. The use of flattening-filter–free decreased treatment time compared with the flat beam mode in our VMAT (p < 0.05). For the 48 patients, there were no significant differences in the lateral, longitudinal, and vertical directions between OSMS and cone beam CT.

DIBH-VMAT with OSMS is very feasible in daily practice with excellent patient compliance in our single-center experience. Note that OSMS is an effective tool that may allow easier-to-achieve precise positioning and better and shorter position-verify time. Meanwhile, compared with FB, DIBH was characterized by lower doses to OARs, which may reduce the probability of cardiac and pulmonary complications in the future.

• DIBH
• OSMS
• VMAT
• breast cancer
• radiotherapy

• Breast edema
• Breast neoplasms
• Clinimetric properties
• Questionnaire
• Reliability
• Validity

• Adult
• Breast Neoplasms/pathology
• Disability Evaluation
• Disabled Persons
• Edema/diagnosis
• Edema/pathology
• Female
• Humans
• Middle Aged
• Quality of Life/psychology
• Reproducibility of Results
• Surveys and Questionnaires

• G078 Vlaamse regering

Adjuvant whole breast radiotherapy is the standard of care for breast cancer patients after partial mastectomy. Intensity-modulated radiation therapy (IMRT) has been reported to reduce acute toxicities compared to conventional radiotherapy. IMRT with simultaneous integrated boost (SIB) technique can deliver higher doses to tumor bed and irradiate whole breast with a lower dose level to shorten overall treatment duration. This study presents the long-term results of adjuvant IMRT with SIB in elderly breast cancer patients who received partial mastectomy.

From January 2007 to January 2018, 93 elder breast cancer patients (≥65-year-old) who received IMRT with SIB technique after partial mastectomy were reviewed retrospectively. The axillary areas were managed with either sentinel lymph node biopsies or axillary lymph node dissection. The dose to whole breast was 50.4 Gy in 28 fractions in all patients and the dose to tumor bed was 61.6 to 66.4 Gy in 28 fractions. The primary end point is locoregional control. Secondary end points include: overall survival, breast cancer-specific survival, distant-metastases-free survival, disease-free survival, and acute and chronic toxicities.

The median follow-up was 56.1 months. One patient had ipsilateral breast tumor recurrence, 3 patients had regional lymph node recurrence, and 9 patients had distant metastases. Death occurred in 5 patients, including 3 patients died of breast cancer progression. Five-year overall survival is 96.3% and 5-year locoregional recurrence-free survival is 96.4%. The 5-year breast cancer specific survival and 5-year distant metastases-free survival is 97.5% and 87.2%, respectively. Seven patients developed second primary cancer after RT. Eighty-one point seven percent patients had acute grade 1 dermatitis while 18.3% suffered from grade 2 dermatitis. The incidence of grade 1 pneumonitis and grade 1 stomatitis was 4.3% and 8.6%, respectively.

Adjuvant IMRT with SIB technique is a safe and effective treatment strategy for elderly breast cancer patients after partial mastectomy.

• Breast cancer
• elderly
• intensity-modulated radiotherapy
• radiotherapy
• simultaneous integrated boost

• breast cancer
• chest wall irradiation
• intensity-modulated radiotherapy
• lymphatic irradiation
• three-dimensional conformal radiotherapy

• Female
• Humans
• Lymphatic Irradiation/methods
• Organs at Risk/radiation effects
• Radiotherapy Dosage
• Radiotherapy Planning, Computer-Assisted/methods
• Radiotherapy, Conformal/methods
• Radiotherapy, Intensity-Modulated/methods
• Thoracic Wall/radiation effects
• Unilateral Breast Neoplasms/radiotherapy

• breast cancer
• lymph node dissection
• radiation therapy
• skin thickening
• toxicity

To develop an one-click option on treatment planning system that enables for the automated breast FIF planning by combining the Eclipse Scripting application programming interfaces and user-executed programming in Windows.

Scripting application programming interfaces were designed to promote automation in clinical workflow associated with radiation oncology. However, scripting cannot provide all functions that users want to perform. Thus, a new framework proposes to integrate the benefits of the scripting application and user-executed programming for the automated field-in-field technique. We adopted the Eclipse Scripting applications, which provide an interface between treatment planning system server and client and enable for running the executed program to create dose clouds and adjust the planning parameters such as multi-leaf collimator placements and monitor unit values. Importantly, all tasks are designed to perform with one-click option on treatment planning system, including the automated pushback of the proposed plan to the treatment planning system.

The plans produced from the proposed framework were validated against the manual field-in-field plans with 40 retrospective breast patient cases in planning efficiency and plan quality. The elapsed time for running the framework was less than 1 minute, which significantly reduced the manual multi-leaf collimator/monitor unit adjustment time. It decreased the total planning time by more than 50%, relative to the manual field-in-field planning. In dosimetric aspects, the mean and maximum dose of the heart, lung, and whole breast did not exceed 1% deviation from the manual plans in most patient cases, while maintaining the target dose coverage and homogeneity index inside the target volume. From numerical analysis, the automated plans were demonstrated to be sufficiently close to the manual plans.

The combination of scripting applications and user-executed programming for automated breast field-in-field planning accomplished a significant enhancement in planning efficiency without degrading the plan quality, relative to the manual field-in-field procedure.

• automated framework
• breast radiation therapy
• eclipse scripting API (ESAPI)
• field-in-field (FIF)
• forward IMRT

This study was performed to evaluate skin toxicity during modern three-dimensional conformal radiotherapy (3D-CRT) and to evaluate the importance of dose distribution and patient related factors.

This study comprises 255 patients with breast cancer treated with tangential three-dimensional conformal radiotherapy (3D-CRT) after breast conserving surgery between 03/2012 and 05/2017. The median prescribed dose was 50.4 Gy (range 50–50.4) and 92.2% of the patients received a sequential boost of 10–16 Gy. Adverse skin toxicities (according to CTCAE v. 4.03 and the occurrence of moist desquamations) were assessed at the end of treatment. The dose distribution in the skin (5 mm strip from the patient outline) and in the CTV was evaluated and correlated to the CTCAE scores and the occurrence of moist desquamation.

42.4% of the patients developed grade I, 55.7% grade II and 2% grade III skin toxicities. Moist desquamation was observed in 59 cases (23.1%). Dose distribution within the CTV and skin was homogenous with only small areas receiving 107% of the prescribed dose (median: 0.7 cm³) in the CTV and 105% (median 0.5 cm³) in the skin. On univariate analysis breast size as well as V107%(CTV), V105%(skin) and V80%(skin) correlated significantly (p < 0.05) with the incidence of skin toxicity. On multivariate analysis only V80%(skin) was confirmed as independent risk factor.

Modern tangential multi-field 3D-CRT allows a homogeneous dose distribution with similar skin toxicity as compared to studies performing IMRT. Dose distribution within the skin (V80%) might have a relevant impact on the severity of skin toxicity and the occurrence of moist desquamation.

• 3D-CRT
• Breast cancer
• Prognostic factors
• Radiodermatitis
• Skin

• Atorvastatin
• Radioprotective
• Radiotherapy
• Skin toxicity

To compare late toxicity after postoperative hypofractionated radiotherapy (RT) and standard fractionated RT in patients with early-stage breast carcinoma.

This retrospective study included 447 patients (Modulated Accelerated Radiotherapy [MARA-1]: 317 patients, and control group [CG]: 130 patients). In the CG, the whole breast received 50.4 Gy in 28 fractions (fx) using 3D-radiotherapy, plus a sequential electron boost (10 Gy in 4 fx) to tumor bed. In MARA-1 group, a forward-planned intensity-modulated radiotherapy technique with 40 Gy in 16 fx with a concomitant boost of 4 Gy to breast was used. The primary endpoint was to evaluate late toxicity, and secondary endpoints were acute toxicity, local control, and survival. ClinicalTrials.gov: NCT03461224.

Median follow-up was 52 months (range: 3–115 months). Late skin and subcutaneous toxicity were acceptable: 5-year actuarial cumulative incidence of Grade (G) 3 late skin toxicity was 1.5% in CG and 0.0% in MARA-1. Five-year actuarial cumulative incidence of G3 late subcutaneous toxicity was 0.8% in CG and 0.3% in MARA-1. On multivariate analysis, tobacco smoking and planning target volume were associated with an increased risk of late G1 skin toxicity (HR: 2.15, 95% CI: 1.38–3.34 and HR: 1.12, 95% CI: 1.07–1.18, respectively), whereas patients with a larger planning target volume also showed an increased risk of G1 and G2 late subcutaneous toxicity (HR: 1.14, CI 95%: 1.08–1.20 and HR: 1.14, 95% CI: 1.01–1.28, respectively). MARA-1 patients also showed an increased risk of late G1 and G2 subcutaneous toxicity (HR: 2.35, 95% CI: 1.61–3.41 and HR: 3.07, 95% CI: 1.11–8.53, respectively) compared to CG.

In this retrospective analysis, postoperative accelerated-hypofractionated RT for early-stage-breast carcinoma was associated with higher incidence of subcutaneous side effects. However, this increase was limited to G1–G2 toxicity. In the future, development of predictive models could help in tailoring dose and fractionation based on the risk of toxicity.

• breast cancer
• hypofractionation
• radiotherapy
• retrospective study

• breast cancer
• contouring guidelines
• radiotherapy