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Mutter RW, Golafshar MA, Buras MR, Comstock BP, Jacobson M, DeWees T, Remmes NB, Francis LN, Boughey JC, Ruddy KJ, McGee LA, Afzal A, Vallow LA, Furutani KM, Deufel CL, Shumway DA, Kim H, Liu MC, Degnim AC, Jakub JW, Vern-Gross TZ, Wong WW, Patel SH, Vargas CE, Stish BJ, Waddle MR, Pafundi DH, Halyard MY, Corbin KS, Hieken TJ, Park SS. Dose Deintensified 3-Day Photon, Proton, or Brachytherapy: A Nonrandomized Controlled Partial Breast Irradiation Trial. Int J Radiat Oncol Biol Phys 2025; 121:352-364. [PMID: 39299551 DOI: 10.1016/j.ijrobp.2024.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 08/19/2024] [Accepted: 09/04/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE The optimal approach for partial breast irradiation (PBI) is unknown. We investigated a novel de-intensified 3-fraction PBI regimen for photons, protons, and brachytherapy. METHODS AND MATERIALS A multicenter nonrandomized controlled trial with the primary outcome of adverse cosmesis at 3 years versus before PBI. Eligibility criteria were age ≥50 years treated with breast-conserving surgery for node-negative estrogen receptor-positive (ER+) invasive breast cancer or any ductal carcinoma in situ (DCIS) measuring ≤2.5 cm. Photon and proton PBI were prescribed 21.9 Gy (relative biological effectiveness) and brachytherapy 21 Gy in 3 fractions. Radiation therapy technique and adjuvant endocrine therapy were selected at physician and patient discretion. RESULTS Between June 17, 2015, and July 13, 2017, 161 eligible patients were treated with photons (56), protons (49), or brachytherapy (56). Median patient age was 66.8 years. One hundred twenty-six (78.3%) had invasive breast cancer (all ER+) and 35 (21.7%) had DCIS (88.6% ER+). Fifty-four percent of patients with invasive breast cancer and 25.8% of patients with ER+ DCIS initiated and adhered to the prescribed endocrine therapy. The proportion of patients with adverse cosmesis (by trained nurse assessment) was 14.5% at baseline and 2.3% at 3 years (difference, -12.2%; 95% CI, -100% to -6.4%). Adverse cosmesis at the last follow-up, with a median follow-up of 5 years, was 5.7% by nurse assessment, 5.6% by panel assessment of digital photographs, and 5.2% by patient self-report. There were no observed clinically meaningful changes in other patient-reported outcomes, and just 2 grade 2 or higher adverse events, both grade 2, in the brachytherapy cohort. Five-year local recurrence-free survival and progression-free survival were 98.0% and 95.5%, respectively. There were no local recurrences among 60 patients with invasive breast cancer and Ki67 ≤13.25%. CONCLUSIONS Deintensified 3-day PBI provided favorable disease control, tolerability, and cosmetic outcomes, meeting the prespecified criteria for acceptability. This approach is an attractive option for patients with small node-negative ER+ breast cancer and DCIS.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota.
| | - Michael A Golafshar
- Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona
| | - Matthew R Buras
- Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona
| | - Bryce P Comstock
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Maddi Jacobson
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Todd DeWees
- Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona
| | | | - Leah N Francis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Judy C Boughey
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kathryn J Ruddy
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Arslan Afzal
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Laura A Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Keith M Furutani
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Haeyoung Kim
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota; Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Minetta C Liu
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | - Amy C Degnim
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - James W Jakub
- Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | | | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Deanna H Pafundi
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Burkon P, Selingerova I, Vrzal M, Holanek M, Coufal O, Polachova K, Andraskova V, Jhawar SR, Slampa P, Kazda T, Slavik M. Quality of life in early breast cancer patients after adjuvant accelerated partial-breast irradiation (APBI) in randomized trial. Sci Rep 2025; 15:1387. [PMID: 39779797 PMCID: PMC11711455 DOI: 10.1038/s41598-025-85342-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Accepted: 01/02/2025] [Indexed: 01/11/2025] Open
Abstract
Accelerated partial breast irradiation (APBI) represents a valid option for adjuvant therapy of selected early breast cancer (BC). This single-institution prospective randomized study compares the health-related quality of life (HRQoL) between women treated with the highly conformal-external beam APBI technique and those with the more commonly used moderately hypofractionated whole breast irradiation (hypo-WBI). Eligible patients were women over 50 years with early BC (G1/2 DCIS ≤ 25 mm or G1/2 invasive non-lobular luminal-like HER2 negative carcinoma ≤ 20 mm) after breast-conserving surgery with negative margins. APBI arm consisted of 30 Gy in 5 consecutive daily fractions and WBI arm of 40 Gy in 15 fractions plus 10 Gy in 5 fractions boost to the tumor bed. Patients were requested to complete the official Czech translation of the EORTC QoL questionnaires, including QLQ-C30 and QLQ-BR45, before radiation (baseline), at the end of radiation (M0) and 1 (M1), 3 (M3), 6 (M6), 12 (M12), and 24 (M24) months after radiation. Linear regression models were used to analyze differences in HRQoL between the arms. The 85 enrolled patients exhibited no differences in HRQoL scores between the two arms at baseline. Patients in the APBI arm reported more favorable global health status at M6 (p = 0.055). Other functional scales showed a decrease in the WBI arm at M0 (p = 0.027 for physical functioning). During radiation, symptoms scores increased. Significant between-group differences were observed for the pain (p = 0.002), systemic therapy side effects (p = 0.004), and breast symptoms (p < 0.001) scales at M0, with higher scores in the WBI arm. During follow-up, scores on symptoms scales returned to at least the baseline values. Early BC patients treated with APBI showed non-inferior short-term and late HRQoL outcomes compared to hypo-WBI. In addition to previous findings regarding toxicity, promising pain and breast symptoms results, suggest that APBI should be strongly considered as a treatment option for selected low-risk patients.Trial registration NCT06007118, August 23, 2023 (retrospectively registered).
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Affiliation(s)
- Petr Burkon
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 656 53, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Iveta Selingerova
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 656 53, Czech Republic.
- Department of Mathematics and Statistics, Faculty of Science, Masaryk University, Brno, Czech Republic.
| | - Miroslav Vrzal
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 656 53, Czech Republic
| | - Milos Holanek
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Oldrich Coufal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Katerina Polachova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 656 53, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Vera Andraskova
- Clinical Nutrition Unit, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Sachin R Jhawar
- Radiation Oncology Department, Arthur James Cancer Center, The Ohio State University, Columbus, USA
| | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 656 53, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 656 53, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 656 53, Czech Republic
| | - Marek Slavik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty kopec 7, Brno, 656 53, Czech Republic.
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
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Takahashi K, Kagami Y, Yoshimura R, Morota M, Murakami N, Nakamura S, Okamoto H, Nagao A, Sakuramachi M, Kashihara T, Kaneda T, Inaba K, Okuma K, Nakayama Y, Itami J, Igaki H. Prospective study of once-daily accelerated partial breast irradiation using 3-dimensional conformal external beam radiotherapy for Japanese women: 12-year outcomes, toxicity, and cosmesis. Breast Cancer 2025; 32:197-207. [PMID: 39630209 PMCID: PMC11717833 DOI: 10.1007/s12282-024-01650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Accepted: 11/09/2024] [Indexed: 01/11/2025]
Abstract
BACKGROUND To analyze in a prospective study the long-term safety and efficacy of 3-dimensional conformal radiotherapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI) for Japanese women with early breast cancer. METHODS Breast cancer patients with pathological tumor size ≤ 3 cm, age ≥ 20 years, lumpectomy with at least a 5 mm margin, and ≤ 3 positive axillary nodes were eligible. APBI was delivered by 3D-CRT at a dose of 38.5 Gy in 10 fractions over 10 days. The primary endpoints were the frequency and severity of acute and late radiation toxicities, and secondary endpoints were local control, survival, and cosmesis. The sample size was determined based on the incidence of ≥ grade 3 acute and late radiation toxicities, which required 71 enrollments. RESULTS Between 2008 and 2010, 73 patients enrolled in this trial. Twelve patients (16%) had 1-3 lymph node metastases. At a median follow-up of 12.6 years (range: 2.7-13.9 years), there were no cases of grade ≥ 3 acute or late toxicity. There were 4 ipsilateral breast tumor recurrence (IBTR) events: 12-year IBTR incidence was 4.4%. The difference in the incidence of IBTR between node-negative and node-positive patients was marginal (1.9% vs. 16.7%, p = 0.055). The majority of patients (94.4% at 2 years, 89.3% at 10 years after enrollment) had excellent/good cosmesis. CONCLUSIONS APBI delivered with 3D-CRT is a feasible treatment option for Asian females, but it was indicated that node-positive status might increase IBTR risk.
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Affiliation(s)
- Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Yoshikazu Kagami
- Department of Radiation Oncology, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Ryoichi Yoshimura
- Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Madoka Morota
- Department of Radiation Oncology, Showa University Koto Toyosu Hospital, 5-1-38 Toyosu, Koto-ku, Tokyo, 135-0061, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Satoshi Nakamura
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hiroyuki Okamoto
- Division of Radiation Safety and Quality Assurance, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Madoka Sakuramachi
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Tomoya Kaneda
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yuko Nakayama
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Jun Itami
- Shin-Matsudo Accuracy Radiation Therapy Center, Shin-Matsudo Central General Hospital, Shin-Matsudo 1-380, Matsudo-City, Chiba, 270-0034, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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Colciago RR, La Rocca E, Giandini C, Carnevale MG, Bianchi GV, Maugeri I, Depretto C, Meroni S, Cavallo A, Pignoli E, Lozza L, Rancati T, De Santis MC. Fat necrosis after accelerated partial breast irradiation or hypofractionated whole breast irradiation: A case-control study. TUMORI JOURNAL 2024; 110:451-461. [PMID: 39450849 PMCID: PMC11571601 DOI: 10.1177/03008916241291305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 09/11/2024] [Accepted: 09/25/2024] [Indexed: 10/26/2024]
Abstract
PURPOSE This study aimed to compare the incidence of fat necrosis after accelerated partial breast irradiation (APBI) vs hypofractionated whole breast irradiation (WBI) in patients with early-stage breast cancer. MATERIALS AND METHODS Data from early-stage breast cancer patients who underwent breast-conserving surgery and adjuvant radiotherapy between 2009 and 2022 were retrospectively collected. Radiation therapy consisted of APBI of 30 Gy in 5 daily fractions (Fx) (delivered in one week, consecutively) to the tumour bed or WBI (42.4 Gy in 16 Fx). Reports on fat necrosis were extracted from yearly mammograms and breast ultrasound imaging. The primary endpoint was the incidence of radiologically detected fat necrosis. RESULTS A total of 536 patients were included among the APBI and WBI cohorts, with 268 and 268 patients respectively. The three-year Kaplan-Meier actuarial rate of fat necrosis was 32.8% (95% CI: 30.0% - 35.6%) for APBI and 22.3% (95% CI: 19.7% - 24.9%) for WBI patients. Univariate Kaplan-Meier survival analysis revealed a Hazard Ratio of 1.6 [95% CI: 1.1 - 2.2; p = 0.0055] for the fat necrosis rate within the APBI group compared to WBI. Multivariate Cox proportional hazard regression confirmed significant associations between fat necrosis and APBI (HR = 2.2 95% CI: 1.2 - 4.0; p = 0.01). CONCLUSIONS The occurrence of radiologically diagnosed fat necrosis was higher in the APBI group compared to the WBI. Further investigations aiming to identify a lower-dose schedule with comparable efficacy to 30 Gy in 5 Fx but fewer toxicities, particularly for high-risk patients, are warranted.
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Affiliation(s)
- Riccardo Ray Colciago
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- School of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Eliana La Rocca
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Integrata, Verona, Italy
| | - Carlotta Giandini
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Maria Grazia Carnevale
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Giulia Valeria Bianchi
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Ilaria Maugeri
- Breast Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Catherine Depretto
- Breast Imaging Unit, Radiology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Silvia Meroni
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Anna Cavallo
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Laura Lozza
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Tiziana Rancati
- Data Science Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Maria Carmen De Santis
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
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Hepel JT, Leonard KL, Yashar CM, Einck JP, Sha SJ, DiPetrillo TA, Wiggins DL, Graves TA, Edmonson DA, Gass JS, Rivard MJ, Wazer DE. Phase II Trial of Five-Fraction Accelerated Partial Breast Irradiation Using Noninvasive Image-Guided Breast Brachytherapy. Int J Radiat Oncol Biol Phys 2024; 119:878-883. [PMID: 38151190 DOI: 10.1016/j.ijrobp.2023.12.026] [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: 09/08/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE/OBJECTIVE(S) NIBB has potential advantages over other APBI techniques by delivering highly conformal radiation with minimal collateral dose to the heart and lung compared with external beam techniques, but unlike other brachytherapy techniques NIBB is non-invasive. Previous data has shown encouraging outcomes using a 10-fraction regimen. To improve efficiency, convenience, and cost, reduction in the fraction number is desirable. Final results of a prospective phase II trial are reported. MATERIALS/METHODS NIBB APBI was delivered using 28.5Gy in 5 fractions daily over 1 week. Patient eligibility criteria required: invasive carcinoma ≤2.0 cm or DCIS ≤3.0 cm, ER positive (if invasive), lymph node negative, LVI absent, and lumpectomy with margins negative by 2mm. The primary endpoint was grade ≥ 2 subcutaneous fibrosis/induration <30%. Secondary endpoints included any late toxicity, cosmetic outcome, and local control. RESULTS 40 patients were treated with a median follow-up of 59.7 months. The mean age was 67 years (50-89 years) and tumor size was 1.0cm (0.3-2.0cm). 80% had invasive carcinoma. The mean breast separation with compression was 6.7cm (3.5-8.9cm). The 5-year actuarial local control was 96.6% and overall survival was 96.9%. Grade 2 and 3 late toxicities were 15% and 0%, respectively. The rate of grade 2 subcutaneous fibrosis/induration was 2.5% (+/-2.5%) meeting the study's primary endpoint. The most common late toxicity of any grade was skin telangiectasia; 22.5% grade 1 and 15% grade 2. Only breast separation was associated with telangiectasia risk, p=0.002. Overall cosmetic outcome was excellent, good, and fair/poor in 75%, 25%, and 0%, respectively. CONCLUSIONS NIBB APBI delivered in 5 fractions results in a low rate of late toxicity and a high rate of good/excellent cosmetic outcomes. Telangiectasia risk can be minimized by keeping breast separation ≤7.0cm. The local failure rate was appropriately low. Further investigation of this technique is warranted.
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Affiliation(s)
- Jaroslaw T Hepel
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, Massachusetts; Brown University, Providence, Rhode Island.
| | - Kara L Leonard
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, Massachusetts; Brown University, Providence, Rhode Island
| | - Catheryn M Yashar
- Department of Radiation Oncology, University of California, San Diego, La Jolla, California
| | - John P Einck
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas
| | - Sandra J Sha
- Department of Radiation Oncology, Watson Clinic, Lakeland, Florida
| | - Thomas A DiPetrillo
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, Massachusetts; Brown University, Providence, Rhode Island
| | - Doreen L Wiggins
- Brown University, Providence, Rhode Island; Department of Surgery, Rhode Island Hospital, Providence, Rhode Island
| | - Theresa A Graves
- Brown University, Providence, Rhode Island; Department of Surgery, Rhode Island Hospital, Providence, Rhode Island
| | - David A Edmonson
- Brown University, Providence, Rhode Island; Department of Surgery, Women and Infants Hospital, Providence, Rhode Island
| | - Jennifer S Gass
- Brown University, Providence, Rhode Island; Department of Surgery, Women and Infants Hospital, Providence, Rhode Island
| | - Mark J Rivard
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, Massachusetts; Brown University, Providence, Rhode Island
| | - David E Wazer
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, Massachusetts; Brown University, Providence, Rhode Island
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Washington I, Palm RF, White J, Rosenberg SA, Ataya D. The Role of MRI in Breast Cancer and Breast Conservation Therapy. Cancers (Basel) 2024; 16:2122. [PMID: 38893241 PMCID: PMC11171236 DOI: 10.3390/cancers16112122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/19/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Contrast-enhanced breast MRI has an established role in aiding in the detection, evaluation, and management of breast cancer. This article discusses MRI sequences, the clinical utility of MRI, and how MRI has been evaluated for use in breast radiotherapy treatment planning. We highlight the contribution of MRI in the decision-making regarding selecting appropriate candidates for breast conservation therapy and review the emerging role of MRI-guided breast radiotherapy.
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Affiliation(s)
- Iman Washington
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Russell F. Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Julia White
- Department of Radiation Oncology, The University of Kansas Medical Center, 4001 Rainbow Blvd, Kansas City, KS 66160, USA;
| | - Stephen A. Rosenberg
- Department of Radiation Therapy, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Dana Ataya
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, 10920 N. McKinley Drive, Tampa, FL 33612, USA;
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Sato K, Fuchikami H, Takeda N, Natsume N, Kato M. Preliminary report on ultrashort perioperative partial-breast irradiation with multicatheter interstitial brachytherapy for early-stage breast cancer. Breast Cancer 2024; 31:382-390. [PMID: 38363473 DOI: 10.1007/s12282-024-01546-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/16/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE Perioperative partial-breast irradiation (PBI) with multicatheter interstitial brachytherapy (MIB) is less invasive and more convenient than postoperative one. This study aimed to compare ultrashort perioperative MIB-PBI (uPBI) and conventional perioperative MIB-PBI (cPBI) performed during the same period of time. METHODS Inclusion criteria of the study were patients aged ≥ 40 years and those with T0-2 (≤ 3 cm), N0-mi, and negative margins on mammography. The locoregional recurrence (LRR) and toxicity rates were compared between uPBI at a dose of 25.2 Gy in four fractions and cPBI at a dose of 32 Gy in eight fractions. RESULTS In total, 198 patients (151 with uPBI and 47 with cPBI) were evaluated. At a median follow-up of 20.1 months, one (0.66%) patient in the uPBI group had LRR. The 2-year ipsilateral breast tumor recurrence-free survival rates of the uPBI and cPBI groups were 98.7% and 100%, respectively. The highest toxicity grades were grade 1 in 23 (15.2%) and grade 2 in 2 (1.3%) patients in the uPBI group, and grade 1 in 8 (17.0%) and grade 2 in 1 (2.1%) patient in the cPBI group. None of the patients in the two groups presented with grade 3 and higher toxicities. The toxicity rates between the two groups did not significantly differ. Further, 22 (14.6%) patients in the uPBI group and 8 (17.0%) in the cPBI group, and 3 (2.0%) patients in the uPBI group and 1 (2.1%) in the cPBI had acute and late toxicities, respectively. The timing of toxicity development between the two groups did not significantly differ. CONCLUSIONS Although this preliminary report included a small sample size and had a short follow-up period, the local control and toxicity rates were similar between the uPBI and cPBI groups. Further research is warranted to investigate the ideal dose schedule of MIB-PBI.
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Affiliation(s)
- Kazuhiko Sato
- Department of Breast Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan.
| | - Hiromi Fuchikami
- Department of Breast Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan
| | - Naoko Takeda
- Department of Breast Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan
| | - Nana Natsume
- Department of Radiation Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan
| | - Masahiro Kato
- Department of Radiation Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan
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Nichols EM, Bentzen SM, Milburn M, Kesmodel SB, Bellavance E, Becker SJ, Mutaf Y, Tkaczuk K, Rosenblatt P, Feigenberg SJ. A Prospective Trial of Single-Fraction Radiation to the Tumor Bed with a Novel Breast-Specific Stereotactic Radiation Therapy Device: The GammaPod. Adv Radiat Oncol 2024; 9:101398. [PMID: 38778822 PMCID: PMC11110030 DOI: 10.1016/j.adro.2023.101398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 09/24/2023] [Indexed: 05/25/2024] Open
Abstract
Purpose Radiation therapy for early-stage breast cancer is typically delivered in a hypofractionated regimen to the whole breast followed by a tumor bed boost. This results in a treatment course of approximately 4 weeks. In this study, the tumor bed boost was delivered in a single fraction as part of a safety and feasibility study for FDA clearance of the device. Methods and Materials Eligible women with early-stage breast cancer underwent lumpectomy followed by radiation therapy. Patients underwent breast immobilization using a system specific to the GammaPod followed by CT simulation, boost treatment planning, and boost treatment delivery all in a single treatment day. Patients then started whole-breast radiation therapy within 1 week of the boost treatment. Patients and treatments were assessed for safety and feasibility. Acute toxicities were recorded. Results A single-fraction boost of 8 Gy was delivered to the tumor bed before a course of whole-breast radiation. The GammaPod treatment was successfully delivered to 14 of 17 enrolled patients. Acute toxicities from all radiation therapy, inclusive of the boost and whole-breast radiation, were limited to grade 1 events. Conclusions The GammaPod device successfully delivered a single-fraction boost treatment to the tumor bed with no change in expected acute toxicities. The results of this study led to FDA clearance of the device through the Investigational Device Exemption process at the FDA. The GammaPod is in clinical use at 4e institutions nationally and internationally, with additional sites pending in 2023.
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Affiliation(s)
- Elizabeth M. Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Søren M. Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | - Steven J. Feigenberg
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Burkon P, Selingerova I, Slavik M, Holanek M, Vrzal M, Coufal O, Polachova K, Muller P, Slampa P, Kazda T. Toxicity of external beam accelerated partial-breast irradiation (APBI) in adjuvant therapy of early-stage breast cancer: prospective randomized study. Radiat Oncol 2024; 19:17. [PMID: 38310249 PMCID: PMC10837889 DOI: 10.1186/s13014-024-02412-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/29/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Accelerated partial breast irradiation (APBI) is an alternative breast-conserving therapy approach where radiation is delivered in less time compared to whole breast irradiation (WBI), resulting in improved patient convenience, less toxicity, and cost savings. This prospective randomized study compares the external beam APBI with commonly used moderate hypofractionated WBI in terms of feasibility, safety, tolerance, and cosmetic effects. METHODS Early breast cancer patients after partial mastectomy were equally randomized into two arms- external APBI and moderate hypofractionated WBI. External beam technique using available technical innovations commonly used in targeted hypofractionated radiotherapy to minimize irradiated volumes was used (cone beam computed tomography navigation to clips in the tumor bed, deep inspiration breath hold technique, volumetric modulated arc therapy dose application, using flattening filter free beams and the six degrees of freedom robotic treatment couch). Cosmetics results and toxicity were evaluated using questionnaires, CTCAE criteria, and photo documentation. RESULTS The analysis of 84 patients with a median age of 64 years showed significantly fewer acute adverse events in the APBI arm regarding skin reactions, local and general symptoms during a median follow-up of 37 months (range 21-45 months). A significant difference in favor of the APBI arm in grade ≥ 2 late skin toxicity was observed (p = 0.026). Late toxicity in the breast area (deformation, edema, fibrosis, and pain), affecting the quality of life and cosmetic effect, occurred in 61% and 17% of patients in WBI and APBI arms, respectively. The cosmetic effect was more favorable in the APBI arm, especially 6 to 12 months after the radiotherapy. CONCLUSION External APBI demonstrated better feasibility and less toxicity than the standard regimen in the adjuvant setting for treating early breast cancer patients. The presented study confirmed the level of evidence for establishing the external APBI in daily clinical practice. TRIAL REGISTRATION NCT06007118.
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Affiliation(s)
- Petr Burkon
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Iveta Selingerova
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53, Brno, Czech Republic.
- Department of Mathematics and Statistics, Faculty of Science, Masaryk University, Brno, Czech Republic.
| | - Marek Slavik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Milos Holanek
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Miroslav Vrzal
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Oldrich Coufal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Katerina Polachova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Muller
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53, Brno, Czech Republic
| | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53, Brno, Czech Republic
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10
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Freedman GM, Li T, Garver E, Shillington K, Shinkle B, Tchou JC, Fayanju OM, Lin L, Taunk NK. Five-Year Outcomes of a Phase 1/2 Trial of Accelerated Partial Breast Irradiation Using Proton Therapy for Women With Stage 0-IIA Breast Cancer. Adv Radiat Oncol 2024; 9:101334. [PMID: 38405317 PMCID: PMC10885562 DOI: 10.1016/j.adro.2023.101334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/21/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose We report the results of a phase 1/2 trial of external beam partial breast radiation using proton therapy. Methods and Materials Eligible patients included stage 0-IIA breast cancer pTis-T2, N0, and size ≤3 cm. Proton beam radiation was used to deliver 3.85 Gy twice daily to 38.5 Gy. The phase 1 portion determined feasibility based on criteria of successful plan creation, treatment delivery, and acute toxicity grade ≥3 in ≤20% of patients. The phase 2 portion had efficacy goals of acute toxicity grade ≥3 in ≤20% of patients and observing physician-rated cosmesis of excellent or good >85% of patients at 2 years. Results From April 2013 to March 2015, there were 12 patients enrolled onto the phase 1 portion, and the preplanned analysis of feasibility was met in all 4 required criteria. From July 2015 through December 2019 there were 28 patients with 29 treated breasts (1 bilateral) enrolled onto the phase 2 portion of the trial out of 45 originally planned. The trial was closed to accrual because of the coronavirus pandemic and not reopened. Thirty-eight breasts were treated with double-scattering and 3 pencil-beam scanning protons. The median follow-up of the 40 patients is 5.4 years (range, 2.3-8.6 years). There was 1 local recurrence. There was no grade ≥3 acute or late toxicity. At baseline all patients had physician-rated cosmesis good or excellent but at 2 years was excellent in 56%, good in 19%, and fair in 25%. Conclusions Proton-accelerated partial breast irradiation delivered with a twice-daily fractionation was feasible and associated with very low acute and long-term toxicity. However, the trial did not meet goals for cosmesis outcomes and was closed prematurely. Future study is needed to determine whether pencil-beam scanning protons or different fractionation could improve these outcomes.
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Affiliation(s)
- Gary M. Freedman
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Taoran Li
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Garver
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Katherine Shillington
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bridget Shinkle
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia C. Tchou
- Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Oluwadamilola M. Fayanju
- Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lilie Lin
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Neil K. Taunk
- Department of Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania
- Abramson Cancer Center, The University of Pennsylvania, Philadelphia, Pennsylvania
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11
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Zerella MA, Zaffaroni M, Ronci G, Dicuonzo S, Rojas DP, Morra A, Gerardi MA, Fodor C, Rondi E, Vigorito S, Penco S, Sargenti M, Baratella P, Vicini E, Morigi C, Kahler-Ribeiro-Fontana S, Galimberti VE, Gandini S, De Camilli E, Renne G, Cattani F, Veronesi P, Orecchia R, Jereczek-Fossa BA, Leonardi MC. A narrative review for radiation oncologists to implement preoperative partial breast irradiation. LA RADIOLOGIA MEDICA 2023; 128:1553-1570. [PMID: 37650981 DOI: 10.1007/s11547-023-01706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
The strategy to anticipate radiotherapy (RT) before surgery, for breast cancer (BC) treatment, has recently generated a renewed interest. Historically, preoperative RT has remained confined either to highly selected patients, in the context of personalized therapy, or to clinical research protocols. Nevertheless, in the recent years, thanks to technological advances and increased tumor biology understanding, RT has undergone great changes that have also impacted the preoperative settings, embracing the modern approach to breast cancer. In particular, the reappraisal of preoperative RT can be viewed within the broader view of personalized and tailored medicine. In fact, preoperative accelerated partial breast irradiation (APBI) allows a more precise target delineation, with less variability in contouring among radiation oncologists, and a smaller treatment volume, possibly leading to lower toxicity and to dose escalation programs. The aim of the present review, which represents a benchmark study for the AIRC IG-23118, is to report available data on different technical aspects of preoperative RT including dosimetric studies, patient's selection and set-up, constraints, target delineation and clinical results. These data, along with the ones that will become available from ongoing studies, may inform the design of the future trials and representing a step toward a tailored APBI approach with the potential to challenge the current treatment paradigm in early-stage BC.Trial registration: The study is registered at clinicaltrials.gov (NCT04679454).
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Affiliation(s)
- Maria Alessia Zerella
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Mattia Zaffaroni
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Giuseppe Ronci
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Damaris Patricia Rojas
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Anna Morra
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | | | - Cristiana Fodor
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Elena Rondi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Sabrina Vigorito
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Silvia Penco
- Division of Breast Radiology, IRCSS, IEO European Institute of Oncology, Milan, Italy
| | - Manuela Sargenti
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paola Baratella
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Elisa Vicini
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Consuelo Morigi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | | | - Sara Gandini
- Department of Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Elisa De Camilli
- Department of Pathology and Laboratory Medicine, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Renne
- Department of Pathology and Laboratory Medicine, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Maria Cristina Leonardi
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy.
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12
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Shumway DA, Corbin KS, Farah MH, Viola KE, Nayfeh T, Saadi S, Shah V, Hasan B, Shah S, Mohammed K, Riaz IB, Prokop LJ, Murad MH, Wang Z. Partial breast irradiation compared with whole breast irradiation: a systematic review and meta-analysis. J Natl Cancer Inst 2023; 115:1011-1019. [PMID: 37289549 PMCID: PMC10483267 DOI: 10.1093/jnci/djad100] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Early-stage breast cancer is among the most common cancer diagnoses. Adjuvant radiotherapy is an essential component of breast-conserving therapy, and several options exist for tailoring its extent and duration. This study assesses the comparative effectiveness of partial-breast irradiation (PBI) compared with whole-breast irradiation (WBI). METHODS A systematic review was completed to identify relevant randomized clinical trials and comparative observational studies. Independent reviewers working in pairs selected studies and extracted data. Randomized trial results were pooled using a random effects model. Prespecified main outcomes were ipsilateral breast recurrence (IBR), cosmesis, and adverse events (AEs). RESULTS Fourteen randomized clinical trials and 6 comparative observational studies with 17 234 patients evaluated the comparative effectiveness of PBI. PBI was not statistically significantly different from WBI for IBR at 5 years (RR = 1.34, 95% CI = 0.83 to 2.18; high strength of evidence [SOE]) and 10 years (RR = 1.29, 95% CI = 0.87 to 1.91; high SOE). Evidence for cosmetic outcomes was insufficient. Statistically significantly fewer acute AEs were reported with PBI compared with WBI, with no statistically significant difference in late AEs. Data from subgroups according to patient, tumor, and treatment characteristics were insufficient. Intraoperative radiotherapy was associated with higher IBR at 5, 10, and over than 10 years (high SOE) compared with WBI. CONCLUSIONS Ipsilateral breast recurrence was not statistically significantly different between PBI and WBI. Acute AEs were less frequent with PBI. This evidence supports the effectiveness of PBI among selected patients with early-stage, favorable-risk breast cancer who are similar to those represented in the included studies.
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Affiliation(s)
- Dean A Shumway
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Kimberly S Corbin
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Magdoleen H Farah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kelly E Viola
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Samer Saadi
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Vishal Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Bashar Hasan
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Sahrish Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Khaled Mohammed
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Irbaz Bin Riaz
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
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13
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Kubo T, Kurokawa C, Inoue T, Fujii T, Miyaura K, Shinjo H, Kagami Y, Shikama N. Analysis of applicator displacement in accelerated partial breast irradiation using a strut-based design brachytherapy applicator. Brachytherapy 2023; 22:655-664. [PMID: 37455152 DOI: 10.1016/j.brachy.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 05/14/2023] [Accepted: 05/26/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE This study aimed to identify factors associated with strut-adjusted volume implant (SAVI) displacement in accelerated partial breast irradiation (APBI) using a SAVI device. METHODS AND MATERIALS We retrospectively analyzed computed tomography scans taken at the time of treatment planning and immediately before treatment in 61 patients (median age; 55 years, range; 40-85) treated with SAVI and determined the amount of SAVI displacement that occurred between the time from planning to the treatment. The displacement was calculated for the CT axis and SAVI axis, which is related to the SAVI structure. To investigate the cause of the displacement, multivariate analysis was performed on the calculated standard deviation and the insertion angle of SAVI with respect to the sternum in each cross-section, breast density, amount of air around the SAVI, and SAVI length inside the patient to obtain the β coefficient (p-value). RESULTS On the CT coordinate system, positive correlations were observed between the SAVI insertion angle and air volume in the lateral (β coefficient:0.255-0.483) and rotational directions (β coefficient:0.341). On the SAVI coordinate system, positive correlations were observed between the SAVI insertion angle and air volume in all lateral (β coefficient:0.270-0.354) and rotational directions (β coefficient:0.294). A negative correlation was observed between the SAVI length inside the patient and the rotational direction (β coefficient: -0.262). CONCLUSION SAVI insertion angle, the amount of the air outside SAVI and SAVI insertion length are factors which affect the displacement of the applicator. From the results, the applicator displacement and rotation must be <3 mm and 10o in order to meet all the dose criteria. Thus, we should be aware of these factors during insertion of the device to avoid the problem in treatment delivery for the APBI.
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Affiliation(s)
- Tadashi Kubo
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan; Department of Radiotechnology, Showa University Northern Yokohama Hospital, Kanagawa, Japan.
| | - Chie Kurokawa
- Department of Radiation Oncology, Juntendo University, Tokyo, Japan
| | - Tatsuya Inoue
- Department of Radiation Oncology, Juntendo University, Tokyo, Japan
| | - Tomoki Fujii
- Department of Radiotechnology, Showa University Hospital, Tokyo, Japan
| | - Kazunori Miyaura
- Graduate School of Health Sciences, Showa University, Tokyo, Japan
| | - Hidenori Shinjo
- Division of radiation oncology, Department of Radiology, Showa University School of Medicine, Tokyo, Japan
| | - Yoshikazu Kagami
- Division of radiation oncology, Department of Radiology, Showa University School of Medicine, Tokyo, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University, Tokyo, Japan
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14
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Civil YA, Jonker LW, Groot Koerkamp MPM, Duvivier KM, de Vries R, Oei AL, Slotman BJ, van der Velde S, van den Bongard HJGD. Preoperative Partial Breast Irradiation in Patients with Low-Risk Breast Cancer: A Systematic Review of Literature. Ann Surg Oncol 2023; 30:3263-3279. [PMID: 36869253 PMCID: PMC10175515 DOI: 10.1245/s10434-023-13233-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/29/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Preoperative instead of standard postoperative partial breast irradiation (PBI) after breast-conserving surgery (BCS) has the advantage of reducing the irradiated breast volume, toxicity, and number of radiotherapy sessions and can allow tumor downstaging. In this review, we assessed tumor response and clinical outcomes after preoperative PBI. PATIENTS AND METHODS We conducted a systematic review of studies on preoperative PBI in patients with low-risk breast cancer using the databases Ovid Medline, Embase.com, Web of Science (Core Collection), and Scopus (PROSPERO registration CRD42022301435). References of eligible manuscripts were checked for other relevant manuscripts. The primary outcome measure was pathologic complete response (pCR). RESULTS A total of eight prospective and one retrospective cohort study were identified (n = 359). In up to 42% of the patients, pCR was obtained and this increased after a longer interval between radiotherapy and BCS (0.5-8 months). After a maximum median follow-up of 5.0 years, three studies on external beam radiotherapy reported low local recurrence rates (0-3%) and overall survival of 97-100%. Acute toxicity consisted mainly of grade 1 skin toxicity (0-34%) and seroma (0-31%). Late toxicity was predominantly fibrosis grade 1 (46-100%) and grade 2 (10-11%). Cosmetic outcome was good to excellent in 78-100% of the patients. CONCLUSIONS Preoperative PBI showed a higher pCR rate after a longer interval between radiotherapy and BCS. Mild late toxicity and good oncological and cosmetic outcomes were reported. In the ongoing ABLATIVE-2 trial, BCS is performed at a longer interval of 12 months after preoperative PBI aiming to achieve a higher pCR rate.
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Affiliation(s)
- Yasmin A Civil
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands.
| | - Lysanne W Jonker
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Maartje P M Groot Koerkamp
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Katya M Duvivier
- Department of Radiology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ralph de Vries
- Medical Library, Vrije Universiteit, Amsterdam, The Netherlands
| | - Arlene L Oei
- Department of Radiation Oncology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Laboratory for Experimental Oncology and Radiobiology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Center for Experimental Molecular Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - Berend J Slotman
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Susanne van der Velde
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H J G Desirée van den Bongard
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
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15
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Civil YA, Oei AL, Duvivier KM, Bijker N, Meijnen P, Donkers L, Verheijen S, van Kesteren Z, Palacios MA, Schijf LJ, Barbé E, Konings IRHM, -van der Houven van Oordt CWM, Westhoff PG, Meijer HJM, Diepenhorst GMP, Thijssen V, Mouliere F, Slotman BJ, van der Velde S, van den Bongard HJGD. Prediction of pathologic complete response after single-dose MR-guided partial breast irradiation in low-risk breast cancer patients: the ABLATIVE-2 trial-a study protocol. BMC Cancer 2023; 23:419. [PMID: 37161377 PMCID: PMC10169374 DOI: 10.1186/s12885-023-10910-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Partial breast irradiation (PBI) is standard of care in low-risk breast cancer patients after breast-conserving surgery (BCS). Pre-operative PBI can result in tumor downstaging and more precise target definition possibly resulting in less treatment-related toxicity. This study aims to assess the pathologic complete response (pCR) rate one year after MR-guided single-dose pre-operative PBI in low-risk breast cancer patients. METHODS The ABLATIVE-2 trial is a multicenter prospective single-arm trial using single-dose ablative PBI in low-risk breast cancer patients. Patients ≥ 50 years with non-lobular invasive breast cancer ≤ 2 cm, grade 1 or 2, estrogen receptor-positive, HER2-negative, and tumor-negative sentinel node procedure are eligible. A total of 100 patients will be enrolled. PBI treatment planning will be performed using a radiotherapy planning CT and -MRI in treatment position. The treatment delivery will take place on a conventional or MR-guided linear accelerator. The prescribed radiotherapy dose is a single dose of 20 Gy to the tumor, and 15 Gy to the 2 cm of breast tissue surrounding the tumor. Follow-up MRIs, scheduled at baseline, 2 weeks, 3, 6, 9, and 12 months after PBI, are combined with liquid biopsies to identify biomarkers for pCR prediction. BCS will be performed 12 months after radiotherapy or after 6 months, if MRI does not show a radiologic complete response. The primary endpoint is the pCR rate after PBI. Secondary endpoints are radiologic response, toxicity, quality of life, cosmetic outcome, patient distress, oncological outcomes, and the evaluation of biomarkers in liquid biopsies and tumor tissue. Patients will be followed up to 10 years after radiation therapy. DISCUSSION This trial will investigate the pathological tumor response after pre-operative single-dose PBI after 12 months in patients with low-risk breast cancer. In comparison with previous trial outcomes, a longer interval between PBI and BCS of 12 months is expected to increase the pCR rate of 42% after 6-8 months. In addition, response monitoring using MRI and biomarkers will help to predict pCR. Accurate pCR prediction will allow omission of surgery in future patients. TRIAL REGISTRATION The trial was registered prospectively on April 28th 2022 at clinicaltrials.gov (NCT05350722).
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Affiliation(s)
- Yasmin A. Civil
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Arlene L. Oei
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental Molecular Medicine (CEMM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
- Department of Radiation Oncology, Amsterdam UMC Location Universiteit van Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Katya M. Duvivier
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Radiology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Nina Bijker
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Philip Meijnen
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Lorraine Donkers
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Sonja Verheijen
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Zdenko van Kesteren
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Miguel A. Palacios
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Laura J. Schijf
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Radiology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Ellis Barbé
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Inge R. H. M. Konings
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - C. Willemien Menke -van der Houven van Oordt
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Paulien G. Westhoff
- Department of Radiation Oncology, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - Hanneke J. M. Meijer
- Department of Radiation Oncology, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - Gwen M. P. Diepenhorst
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Victor Thijssen
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental Molecular Medicine (CEMM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - Florent Mouliere
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Berend J. Slotman
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Susanne van der Velde
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - H. J. G. Desirée van den Bongard
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
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16
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Yu CX. Radiotherapy of early-stage breast cancer. PRECISION RADIATION ONCOLOGY 2023; 7:67-79. [PMID: 40336616 PMCID: PMC11935132 DOI: 10.1002/pro6.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 01/30/2023] Open
Abstract
Breast cancer is the most prevalent disease for women. With advances in breast cancer screening, most breast cancers are now diagnosed in the early stages. With knowledge of different subtypes and their behavior, breast cancer treatment has become more individualized. Radiation therapy as one of the mainstays of breast cancer treatment has also been evolving. This review attempts to provide a summary of the most influential clinical studies that have driven the technological advances in radiation therapy for early-stage breast cancer.
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Affiliation(s)
- Cedric X. Yu
- Radiation OncologyUniversity of Maryland School of MedicineBaltimoreMarylandUSA
- Xcision Medical SystemsColumbiaMarylandUSA
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17
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Montalvo SK, Kim N, Nwachukwu C, Alluri P, Parsons D, Lin M, Cai B, Zhuang T, Hrycushko B, Chen L, Timmerman R, Rahimi A. On the feasibility of improved target coverage without compromising organs at risk using online adaptive stereotactic partial breast irradiation (A-SPBI). J Appl Clin Med Phys 2022; 24:e13813. [PMID: 36350273 PMCID: PMC9924103 DOI: 10.1002/acm2.13813] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/26/2022] [Accepted: 09/18/2022] [Indexed: 11/11/2022] Open
Abstract
PURPOSE Describe an early-adopting institution's experience with online adaptive radiation for stereotactic partial breast irradiation. METHODS AND MATERIALS Retrospective review of 22 women treated between May 2021 and March 2022 with adaptive stereotactic partial breast irradiation. A total of 106 of 110 fractions were evaluated for dosimetric changes in target coverage and organ-at-risk (OAR) dose. Patient set up with stereotactic wooden frame and adapted per fraction. Treatment and planning times were collected prospectively by radiation therapists. RESULTS Scheduled PTV30 Gy was <95% in 72.1% and <90% in 38.5% of fractions, and both PTV and CTV coverage were improved significantly after adaption, and 83.7% of fractions were delivered as adapted per physician choice. There was no difference in OAR coverage. Average adaptive treatment planning took 15 min and average time-on-couch was 34.4 min. CONCLUSIONS Adaptive stereotactic breast irradiation resulted in improved target coverage with equivalent dosing to OARs in an efficient and tolerated treatment time. Improved target coverage allowed for decreased PTV margins compared to prior trial protocols that may improve acute and late toxicities.
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Affiliation(s)
- Steven K. Montalvo
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Nathan Kim
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Chika Nwachukwu
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Prasanna Alluri
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - David Parsons
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Mu‐Han Lin
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Bin Cai
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Tingliang Zhuang
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Brian Hrycushko
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Liyuan Chen
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Robert Timmerman
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
| | - Asal Rahimi
- Department of Radiation OncologyUT Southwestern Harold C. Simmons Cancer CenterDallasTexasUSA
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18
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Anderson B, Arthur D, Hannoun-Levi JM, Kamrava M, Khan A, Kuske R, Scanderbeg D, Shah C, Shaitelman S, Showalter T, Vicini F, Wazer D, Yashar C. Partial breast irradiation: An updated consensus statement from the American brachytherapy society. Brachytherapy 2022; 21:726-747. [PMID: 36117086 DOI: 10.1016/j.brachy.2022.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques. METHODS Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed. RESULTS The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion. CONCLUSIONS This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | | | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Simona Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
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19
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Liu Y, Veale C, Hablitz D, Krontiras H, Dalton A, Meyers K, Dobelbower M, Lancaster R, Bredel M, Parker C, Keene K, Thomas E, Boggs D. Feasibility and Short-Term Toxicity of a Consecutively Delivered Five Fraction Stereotactic Body Radiation Therapy Regimen in Early-Stage Breast Cancer Patients Receiving Partial Breast Irradiation. Front Oncol 2022; 12:901312. [PMID: 35880164 PMCID: PMC9307906 DOI: 10.3389/fonc.2022.901312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background For appropriately selected patients with early-stage breast cancer (ESBC), accelerated partial breast irradiation (APBI) yields equivalent rates of ipsilateral breast tumor recurrence with mixed results in patient-rated cosmesis compared with whole-breast radiotherapy depending on the technique utilized. When utilizing external beam radiotherapy for APBI, techniques to reduce target margins and overall treatment volume are potentially important to decrease rates of long-term adverse cosmesis. Stereotactic body radiotherapy (SBRT) is a promising technique to deliver APBI because of its increased accuracy and sparing of uninvolved breast tissue. We report the initial results of a prospective clinical trial investigating feasibility, safety, and cosmetic outcomes of a daily five-fraction SBRT regimen for APBI. Methods Twenty-three patients with ESBC after lumpectomy who met APBI suitability were enrolled. During lumpectomy, a bioabsorbable three-dimensional fixed array tissue marker (BioZorb™, Hologic, Marlborough, MA) was placed for enhanced visualization of the cavity boundaries. Clinical target volume (CTV) was defined as the delineable cavity plus a 1-cm isotropic expansion followed by a 3-mm isotropic planning target volume (PTV) expansion. Patients received 30 Gy delivered in five planned consecutive daily fractions in either prone or supine positioning depending on individual anatomy. Two patients completed the five-fraction treatments in 9-day interval and 11-day interval due to external circumstances. A maximum PTV of 124cc was allowed to minimize incidence of fat necrosis. Plans utilized 10-MV flattening filter–free beams delivered on a Varian Edge linear accelerator. Local control, toxicity, and nurse/patient-scored cosmesis at pre-treatment baseline, 1 month post-treatment, and at subsequent 6-month intervals were recorded. Results Twenty-three patients were accrued at the time of submission with median follow-up of 6 months. No patients experienced grade ≥3 acute toxicity. Of the 10 events reported probably related to SBRT, nine were grade 1 (n = 9/10, 90%). There was no evidence of difference, deterioration, or change in patient or nurse-scored cosmesis from baseline to 1 and 6 months post-treatment. One patient developed nodal failure shortly after APBI. Conclusions Although longer follow-up is needed to assess long-term toxicity and local control, this study demonstrated a five-fraction SBRT regimen delivered over consecutive days is a safe, efficient, well-tolerated, and cosmetically favorable means of delivering APBI in suitable women. Clinical Trial Registration https://www.clinicaltrials.gov/ct2/show/NCT03643861, NCT03643861.
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Affiliation(s)
- Yilan Liu
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Christopher Veale
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Diana Hablitz
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Helen Krontiras
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Allison Dalton
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Korie Meyers
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael Dobelbower
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rachael Lancaster
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Markus Bredel
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Catherine Parker
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kimberly Keene
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Evan Thomas
- Department of Radiation Oncology, Ohio State University, Columbus, OH, United States
| | - Drexell Boggs
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
- *Correspondence: Drexell Boggs,
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20
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Bazyka DA, Litvinenko OO, Bugaytsov SG, Shakhrai GF. SKIN AND SUBCUTANEOUS ADIPOSE TISSUE DAMAGE AFTER RADIATION THERAPY IN BREAST CANCER PATIENTS. PROBLEMY RADIATSIINOI MEDYTSYNY TA RADIOBIOLOHII 2021; 26:18-35. [PMID: 34965541 DOI: 10.33145/2304-8336-2021-26-18-35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Indexed: 06/14/2023]
Abstract
The analysis of long-term researches of the pathological changes arising in soft tissues at patients with a breast cancer as a result of radical surgical treatment and adjuvant radiotherapy is carried out in work. The article shows that the standard approach to postoperative radiation therapy, which is based only on the prevalence of the primary tumor process is not always justified. Very often it leads to excessive radiation load on the patient's body and the development of local acute and chronic radiation reactions of the skin, subcutaneous tissue and other soft tissues.In this regard, the question of differentiated purpose of radiotherapy acquires special value first of all at patients with small primary prevalence of tumor process. The paper presents the results of studies to study changes in the anterior chest wall in patients with breast cancer. In relation to the conduct of adjuvant radiotherapy more often need to use the concept of personalized radiation therapy. Radical operation, post-radiation early and late pathological changes in soft tissues, disturbance of microcirculation of lymph and blood, disturbance of innervation of vessels of an upper extremity, peripheral nerves in system of a cervical and plexus plexus, leads to intensive degen-erative and dystrophic changes in soft tissues of the upper. and causes morphological changes in them and further progression of reflex neurovascular and neurodystrophic disorders. Based on the data of adverse effects of radio-therapy on the skin and surrounding tissues, as well as to reduce excessive radiation exposure to the patient's body, a differentiated approach to the appointment of adjuvant radiation therapy.
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Affiliation(s)
- D A Bazyka
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Yuriia Illienka St., Kyiv, 04050, Ukraine
| | - O O Litvinenko
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Yuriia Illienka St., Kyiv, 04050, Ukraine
| | - S G Bugaytsov
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Yuriia Illienka St., Kyiv, 04050, Ukraine
| | - G F Shakhrai
- State Institution «National Research Center for Radiation Medicine of the National Academy of Medical Sciences of Ukraine», 53 Yuriia Illienka St., Kyiv, 04050, Ukraine
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21
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Ladbury C, Liu J, Radany E, Vora N, Amini A, Beriwal S, Yashar C, Shah C, Glaser S. An examination of nationwide trends in accelerated partial breast irradiation - The replacement of breast brachytherapy with intraoperative radiotherapy and external beam radiation. Radiother Oncol 2021; 166:79-87. [PMID: 34838893 DOI: 10.1016/j.radonc.2021.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/03/2021] [Accepted: 11/18/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To examine recent modality utilization trends in accelerated partial breast irradiation (APBI) in the National Cancer Database (NCDB) based on the American Society for Radiation Oncology (ASTRO) guidelines. MATERIALS AND METHODS A total of 58,194 patients treated with APBI were identified. Patients were segregated by APBI modality (brachytherapy, external beam radiotherapy [EBRT], and intraoperative radiotherapy ([IORT]). These patients were then further classified by suitability to receive APBI based on ASTRO guidelines. Temporal trends in utilization were evaluated using linear regression. Logistic regression was applied to study factors contributing to APBI modality choice and treatment within the ASTRO suitability groups. RESULTS Patients treated with brachytherapy, EBRT, and IORT comprised 70.5%, 17.5%, and 12.0% of patients treated with APBI. From 2008 to 2017, total APBI cases remained relatively stable (-54.1 cases/year, p = 0.161) while brachytherapy cases decreased by 258.7 cases/year (p < 0.001). EBRT and IORT increased by 51.5 cases/year (p = 0.019) and 153.1 cases/year (p < 0.001), respectively. 40.0% of patients treated with APBI were classified as "suitable", which increased from 2010 to 2017 from 35.3% to 45.3% (slope = 1.51%/year, r2 = 0.61, p = 0.022). In comparison, 36.0% (36.1% in 2010 to 33.1% in 2017) of patients were classified as "cautionary" (slope = -0.33%/year, r2 = 0.63, p = 0.019) and 23.9% (28.6% in 2010 to 21.6% in 2017) of patients were classified as "unsuitable" (slope = -1.18%/year, r2 = 0.67, p = 0.012). CONCLUSIONS While overall APBI utilization has remained stable since 2008, this has been accompanied by a decline in brachytherapy and a rise in IORT. The causes of these trends should be the topic of future research.
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Affiliation(s)
- Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA.
| | - Jason Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA
| | - Eric Radany
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA
| | - Nayana Vora
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA
| | - Sushil Beriwal
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, USA
| | - Catheryn Yashar
- Department of Radiation Oncology, University of California San Diego, San Diego, USA
| | - Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, USA
| | - Scott Glaser
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA.
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22
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Shah C, Al-Hilli Z, Vicini F. Advances in Breast Cancer Radiotherapy: Implications for Current and Future Practice. JCO Oncol Pract 2021; 17:697-706. [PMID: 34652952 DOI: 10.1200/op.21.00635] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) is an essential component in the management of breast cancer. Following breast-conserving surgery (BCS), adjuvant RT is the standard of care for most patients. Traditionally, RT was delivered with standard whole breast irradiation (WBI) over 5-7 weeks following BCS. However, WBI regimens have evolved; hypofractionated WBI now represents the standard approach, reducing the duration of treatment to 3-4 weeks. Over the past year, five-fraction WBI regimens have also emerged as standard of care for some patients based on data from the FAST and FAST-Forward trials. An alternative to WBI that is also available for patients with early-stage breast cancer following BCS is partial breast irradiation, which can reduce the duration of treatment and the volume of breast tissue irradiated. Outcomes from multiple randomized trials with over a 10-year follow-up have demonstrated the safety and efficacy of partial breast irradiation approaches. Single-fraction intraoperative RT has also been evaluated in two prospective trials although the outcomes available, as well as current guidelines, do not support its utilization outside of prospective studies. For patients requiring RT to the regional lymph nodes, data have demonstrated the safety of hypofractionated approaches for those undergoing BCS or mastectomy without reconstruction. Future directions for early-stage breast cancer radiotherapy include the study of even shorter regimens and studies evaluating the omission of RT versus omission of endocrine therapy for favorable-risk patients. Furthermore, studies are also underway evaluating shorter courses of radiation in patients undergoing breast reconstruction and the use of tumor genomics to identify appropriate patients for omission of radiation with limited nodal involvement.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH
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23
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Price AT, Kennedy WR, Henke LE, Brown SR, Green OL, Thomas MA, Ginn J, Zoberi I. Implementing stereotactic accelerated partial breast irradiation using magnetic resonance guided radiation therapy. Radiother Oncol 2021; 164:275-281. [PMID: 34624406 DOI: 10.1016/j.radonc.2021.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 09/06/2021] [Accepted: 09/20/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Accelerated partial breast irradiation (APBI) seeks to reduce irradiated volumes and radiation exposure for patients while maintaining acceptable clinical outcomes. Magnetic resonance image-guided radiotherapy (MRgRT) provides excellent soft-tissue contrast for treatment localization, which can reduce setup uncertainty, thus reducing margins in the external beam setting. Additionally, stereotactic body radiotherapy (SBRT)-style regimens with high gradients can also be executed. This MR-guided stereotactic APBI (MRgS-APBI) approach can be utilized for a lower number of fractions and spare a greater volume of healthy tissues compared to conventional 3D external beam APBI. METHODS Our MRgS-APBI program was developed for two prospective non-randomized phase I/II clinical trials (20Gyx1 and 8.5Gyx3). Both breast SBRT treatment planning and MRgRT delivery techniques were described in this study. Simulation included both CT and MRI with specialized immobilization to accommodate MR-guided setup and cine-MRI treatment gating. Dosimetry data from 48 single-fraction and 19 three-fraction patients were collected and evaluated. This included planning objectives and SBRT-specific indices. During treatment, setup errors were calculated to evaluate setup reproducibility and duty cycle was calculated using cine-MRI data during gated delivery. RESULTS In both the single- and three- fraction trials combined, 88.5% of the possible dosimetric objectives across all patients were met during planning. The majority of the planning objectives were easily achievable indicating the potential for stricter objectives for subsequent S-APBI treatments. The average magnitude of setup uncertainties was 1.0 cm ± 0.6 cm across all treatments. In the three-fraction trial, the average beam-on duty-cycle for the MRI-gated delivery was 83.0 ± 13.0%. There were no technical MRgS-APBI related issues that resulted in discontinuation of treatment across all patients. CONCLUSION SBRT-style dosimetry and delivery for APBI is feasible using MR-guidance. The program development and dosimetric outcomes reported here can serve as a guide for other institutions considering the clinical implementation of MR-guided stereotactic APBI.
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Affiliation(s)
- Alex T Price
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - William R Kennedy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Sean R Brown
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Maria A Thomas
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - John Ginn
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Imran Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States.
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Leonard CE, Wang Y, Asmar L, Lei RY, Howell KT, Henkenberns PL, Johnson TK, Hobart TL, Tole SP, Kercher JM, Widner JL, Barke L, Kaske T, Carter DL. A prospective Phase III trial evaluating patient self-reported pain and cosmesis in accelerated partial breast irradiation utilizing 3-D versus intensity-modulated radiotherapy. Cancer Med 2021; 10:7089-7100. [PMID: 34469056 PMCID: PMC8525102 DOI: 10.1002/cam4.4242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/09/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose/Objective The primary objective is to examine patient self‐assessment of breast pain and cosmesis between three‐dimensional (3D‐CRT) versus intensity‐modulated radiotherapy (IMRT). The secondary objective is to evaluate any relationship of treatment planning conformality of both cohorts to patient‐assessed pain. Assessments were performed at interim 12, 24, 36, and 48 months with a final 5‐year assessment. Materials/Methods In total, 656 patients (3D‐CRT n = 328; IMRT n = 328) were randomly assigned to either IMRT or 3D‐CRT accelerated partial breast radiotherapy to 38.5 Gy in 10 BID 3.85 Gy fractions. Results Median follow‐up was 3 years. Multivariate analysis showed that pain severity significantly decreased from baseline to the 12‐month follow‐up visit (<0.001 for both 3D‐CRT and IMRT) in each cohort. There was significantly less pain at 2 (p = 0.002) and 3 years (0.045) in the IMRT arm versus the 3D‐CRT arm when compared to the baseline pain level. There was no difference in patient‐assessed cosmesis at any follow‐up point; however, although MD‐assessed cosmesis showed no difference from years 1 to 4, there was significantly better cosmesis for 3D‐CRT versus IMRT (p = 0.047) at 5 years. There was a significant correlation between a maximum pain score and an increase in the CI100 (indicating less conformity) in the IMRT cohort (p < 0.01) and in the IMRT subgroup when the CI100 was ≤0.37 cohort arm (p = 0.01). Conclusion In the analysis of our primary objective we found that at 2 years, IMRT resulted in more interval improvement in breast pain after baseline when compared to patients treated with 3D‐CRT planning. As seen in our secondary analysis, this may be due to the ability of IMRT to achieve higher conformality (as evidenced by lower CI values) resulting in less fibrosis. There were no differences in patient‐assessed cosmesis or MD‐assessed cosmesis for years 1–4; however, physician‐assessed 5‐year cosmesis was better with 3D‐CRT.
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Affiliation(s)
| | | | - Lina Asmar
- Linasmar Consulting, Houston, Texas, USA
| | - Rachel Y Lei
- Rocky Mountain Cancer Centers, Littleton, Colorado, USA
| | | | | | | | | | | | | | | | - Lora Barke
- Sally Jobe Diagnostic Breast Center, Greenwood Village, Colorado, USA
| | - Terese Kaske
- Sally Jobe Diagnostic Breast Center, Greenwood Village, Colorado, USA
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25
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Boutrus RR, El Sherif S, Abdelazim Y, Bayomy M, Gaber AS, Farahat A, Hashem T, El Sebaie M. Once Daily Versus Twice Daily External Beam Accelerated Partial Breast Irradiation: A Randomized Prospective Study. Int J Radiat Oncol Biol Phys 2021; 109:1296-1300. [PMID: 33714527 DOI: 10.1016/j.ijrobp.2020.11.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/11/2020] [Accepted: 11/13/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE The aim of the current study was to compare toxicity, cosmesis, and local control between the once daily and the twice daily fractionation schemes for external beam accelerated partial breast irradiation. METHODS AND MATERIALS From December 2012 to June 2018, we enrolled 113 patients with ductal carcinoma in situ or invasive breast cancer, node negative disease, and tumors less than 3 cm in size to receive accelerated partial breast irradiation (APBI) to a total dose of 38.5 Gy over 10 fractions given either once (oAPBI) or twice daily (tAPBI). Sixty patients were included in the tAPBI arm and 53 patients were included in the oAPBI arm. RESULTS Median follow-up was 74 months (range, 24-105). The median pain score during treatment was 3 out of 10 in the oAPBI and 5 in the tAPBI (P = .001). No differences were observed in GIII early skin toxicity (P = .4) or GI early pulmonary toxicity (P = 1.0) between the 2 treatment arms. GIII late skin toxicity developed in 3.8% and 11.7% of patients in the oAPBI and tAPBI arms, respectively (P = .001). GIII subcutaneous fibrosis developed in 1.9% and 8.3% of patients in the oAPBI and tAPBI, respectively (P = .001). The rate of patients with adverse cosmesis (poor/fair) was 7.5% at 12 months and at 24 months in the oAPBI arm compared with 21.7% and 26.7% in the tAPBI arm (P = .03 and .008, respectively). CONCLUSIONS oAPBI is a safe, well-tolerated schedule with more favorable outcomes than the tAPBI schedule with regards to late toxicity and cosmesis.
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Affiliation(s)
- Rimoun R Boutrus
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt.
| | - Sara El Sherif
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Yasser Abdelazim
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohammed Bayomy
- Clinical Oncology Department, Zagazig University, Zagazig, Egypt
| | - Ayman S Gaber
- Medical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmed Farahat
- Surgical Oncology Department, Breast Division, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Tarek Hashem
- Surgical Oncology Department, Breast Division, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Medhat El Sebaie
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
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26
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Li X, Sanz J, Foro P, Martínez A, Zhao M, Reig A, Liu F, Huang Y, Membrive I, Algara M, Rodríguez N. Long-term results of a randomized partial irradiation trial compared to whole breast irradiation in the early stage and low-risk breast cancer patients after conservative surgery. Clin Transl Oncol 2021; 23:2127-2132. [PMID: 33880724 DOI: 10.1007/s12094-021-02618-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To report long-term results of a randomized trial comparing accelerated partial breast irradiation (APBI) to whole-breast irradiation (WBI) in terms of efficacy, toxicity, and cosmesis. METHODS AND MATERIALS WBI group was treated with 3D conformal external irradiation, 2 Gy daily/fraction, 5 fractions/week, to a total dose of 50 Gy. APBI group was treated with 3D conformal external irradiation 3.75 Gy/fraction, twice a day, 5 fractions/week, to a total dose of 37.5 Gy in the APBI group. Patients were followed up every 6 months up to 5 years and yearly thereafter. During follow-up visits, the clinician evaluated chronic toxicity and scored cosmetic results with a four-scale system. RESULTS After a median follow-up of 10.3 years, 43 patients in each group (84%) are alive without disease. One patient died after disease progression in the APBI arm, and there was no death in the WBI arm. The rest of the patients died from another disease different than breast cancer, similarly between groups. There was greater fibrosis in the APBI group (9 patients grade 1 and one grade 2) compared to WBI (3 patients grade 1 and one grade 2); p = 0.18. Regarding cosmesis, in APBI group, 19 and 21 (43.2 and 47%) patients had excellent or good results, similar to the WBI group with 18 patients (40.9%) in each cosmesis outcome. The WBI group did not have any patient with poor cosmesis but the APBI had 3 (6.8%; p = 0.24). CONCLUSION After a follow-up of 10 years, there were no differences in efficacy between the 2 treatment arms. Despite slight greater toxicity in the APBI group, the cosmesis was similar and satisfactory in both groups.
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Affiliation(s)
- X Li
- Universidad Autónoma de Barcelona, Barcelona, Spain
| | - J Sanz
- Universitat Pompeu Fabra, Barcelona, Spain. .,Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain. .,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain.
| | - P Foro
- Universitat Pompeu Fabra, Barcelona, Spain.,Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
| | - A Martínez
- Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain
| | - M Zhao
- Universidad Autónoma de Barcelona, Barcelona, Spain
| | - A Reig
- Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
| | - F Liu
- Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain
| | - Y Huang
- Universidad Autónoma de Barcelona, Barcelona, Spain
| | - I Membrive
- Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
| | - M Algara
- Universidad Autónoma de Barcelona, Barcelona, Spain.,Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
| | - N Rodríguez
- Universitat Pompeu Fabra, Barcelona, Spain.,Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
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Snider JW, Nichols EM, Mutaf YD, Chen S, Molitoris J, Diwanji T, Becker SJ, Feigenberg SJ. Reproducibility of a novel, vacuum-assisted immobilization for breast stereotactic radiotherapy. J Appl Clin Med Phys 2021; 22:8-15. [PMID: 33656237 PMCID: PMC7984473 DOI: 10.1002/acm2.13127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/12/2020] [Accepted: 10/18/2020] [Indexed: 11/13/2022] Open
Abstract
A novel, breast‐specific stereotactic radiotherapy device has been developed for delivery of highly conformal, accelerated partial breast irradiation. This device employs a unique, vacuum‐assisted, breast cup immobilization system that applies a gentle, negative pressure to the target breast with the patient in the prone position. A device‐specific patient loader is utilized for simulation scanning and device docking. Prior to clinical activation, a prospective protocol enrolled 25 patients who had been or were to be treated with breast conservation surgery and adjuvant radiotherapy for localized breast cancer. The patients underwent breast cup placement and two separate CT simulation scans. Surgical clips within the breast were mapped and positions measured against the device’s integrated stereotactic fiducial/coordinate system to confirm reproducible and durable immobilization during the simulation, treatment planning, and delivery process for the device. Of the enrolled 25 patients, 16 were deemed eligible for analysis. Seventy‐three clips (median, 4; mean, 4.6; range, 1–8 per patient) were mapped in these selected patients on both the first and second CT scans. X, Y, and Z coordinates were determined for the center point of each clip. Length of vector change in position was determined for each clip between the two scans. The mean displacement of implanted clips was 1.90 mm (median, 1.47 mm; range, 0.44–6.52 mm) (95% CI, 1.6–2.20 mm). Additional analyses stratified clips by position within the breast and depth into the immobilization cup. Overall, this effort validated the clinically utilized 3‐mm planning target volume margin for accurate, reliable, and precise employment of the device.
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Affiliation(s)
- James W Snider
- Department of Radiation Oncology, University of Alabama at Birmingham Alabama, Birmingham, AL, USA
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yildirim D Mutaf
- Department of Radiation Oncology, Kaiser Permanente, Dublin, CA, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jason Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Miami, Coral Gables, FL, USA
| | - Stewart J Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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28
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Stereotactic body radiotherapy in Cyberknife® for partial breast irradiation: a review. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s146039692000120x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Introduction:
Partial breast irradiation (PBI) can reduce the volume of treatment and number of treatment sessions in low-risk breast cancer patients. Stereotactic body radiotherapy (SBRT) allows the administration of high doses per fraction thereby reducing the number of fractions and reducing the dose to the surrounding tissues. The objective of this study is to review the literature on the use of SBRT in PBI using the Cyberknife® (CK) unit.
Material and methods:
In this review, we analysed the literature in PubMed and MEDLINE with articles published in the last 10 years. All citations were evaluated for relevant content and validity.
Results:
We include articles in the English language with information about PBI, SBRT in PBI, the use of the CK unit in PBI and other applications of SBRT in breast carcinoma. A total of 68 articles were found and 28 articles were selected for inclusion in this review.
Conclusions:
The treatment of PBI using the CK unit has clear advantages in reducing the treatment volume, and therefore theoretically reducing side effects and good cosmetic results with adequate tumour control. However, the placement of fiducial markers is necessary, requiring an adequate learning curve for the placement of the markers and longer treatment times.
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Polgár C, Major T, Takácsi-Nagy Z, Fodor J. Breast-Conserving Surgery Followed by Partial or Whole Breast Irradiation: Twenty-Year Results of a Phase 3 Clinical Study. Int J Radiat Oncol Biol Phys 2020; 109:998-1006. [PMID: 33186620 DOI: 10.1016/j.ijrobp.2020.11.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/22/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE To report the 20-year results of a phase 3 clinical trial comparing the survival and cosmetic results of breast-conserving surgery followed by partial breast irradiation (PBI) or whole breast irradiation (WBI). METHODS AND MATERIALS Between 1998 and 2004, 258 selected patients with low-risk invasive breast carcinoma (pT1 pN0-1mi, grade 1-2, nonlobular breast cancer) resected with negative margins were randomized after breast-conserving surgery to receive PBI (n = 128) or 50 Gy WBI (n = 130). Partial breast irradiation was given either by multicatheter high-dose-rate (HDR) brachytherapy (BT; n = 88) with 7 × 5.2 Gy twice daily or 50 Gy external beam irradiation with electron beams (n = 40). RESULTS Median follow-up time was 17 years. The 20-year actuarial rates of ipsilateral breast tumor recurrences were 9.6% versus 7.9% (P = .59) in the PBI and WBI arms, respectively. There was no significant difference in the 20-year probability of disease-free (79.7% vs 78.3%), cancer-specific (92.6% vs 88.1%), and overall survival (59.5% vs 59.7%). Significantly more patients had excellent or good cosmetic result in the PBI and WBI groups (79.2% vs 59.5%; P = .0007). CONCLUSIONS The 20-year updated results of our phase 3 clinical trial add further scientific evidence that PBI either with multicatheter HDR BT or electron beams for low-risk invasive breast carcinomas yield long-term local tumor control and survival comparable to those achieved with standard WBI. Interstitial HDR BT improved cosmetic results compared with WBI.
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Affiliation(s)
- Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - János Fodor
- Department of Oncology, Semmelweis University, Budapest, Hungary
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30
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Mészáros N, Major T, Stelczer G, Jánváry L, Zaka Z, Pukancsik D, Takácsi-Nagy Z, Md JF, Polgár C. Accelerated partial breast irradiation with 3-dimensional conformal and image-guided intensity-modulated radiotherapy following breast conserving surgery - 7-Year results of a phase II trial. Breast 2020; 54:222-228. [PMID: 33161336 PMCID: PMC7648201 DOI: 10.1016/j.breast.2020.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/05/2020] [Accepted: 10/22/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose To present the 7-year results of accelerated partial breast irradiation (APBI) using three-dimensional conformal (3D-CRT) and image-guided intensity-modulated radiotherapy (IG-IMRT) following breast-conserving surgery (BCS). Patients and methods Between 2006 and 2014, 104 patients were treated with APBI given by means of 3D-CRT using 3–5 non-coplanar, isocentric wedged fields, or IG-IMRT using kV-CBCT. The total dose of APBI was 36.9 Gy (9 × 4.1 Gy) using twice-a-day fractionation. Survival results, side effects and cosmetic results were assessed. Results At a median follow-up of 90 months three (2.9%) local recurrences, one (0.9%) regional recurrence and two (1.9%) distant metastases were observed. The 7-year local (LRFS), recurrence free survival was 98.9%. The 7-year disease-free (DFS), metastases free (MFS) and overall survival (OS) was 94.8%, 97.9% and 94.8%, respectively. Late side effects included G1 skin toxicity in 15 (14.4%), G1, G2, and G3 fibrosis in 26 (25%), 3 (2.9%) and 1 (0.9%) patients respectively. Asymptomatic (G1) fat necrosis occurred in 10 (9.6%) patients. No ≥ G2 or higher late side effects occurred with IMRT. The rate of excellent/good and fair/poor cosmetic results was 93.2% and 6.8%, respectively. Conclusion 7-year results of APBI with 3D-CRT and IG-IMRT are encouraging. Toxicity profile and local tumor control are comparable to other series using multicatheter interstitial brachytherapy. Therefore, these external beam APBI techniques are valid alternatives to whole breast irradiation and brachytherapy based APBI.
Phase II APBI trial using 3D-CRT or IG-IMRT. Twice-a-day fractionation, with a total dose of 36.9 Gy (9 × 4.1Gy). No Grade 2 or worst late side effects with IG-IMRT at median follow up of 90 months. These APBI techniques are valid alternatives to WBI or brachytherapy based APBI.
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Affiliation(s)
- Norbert Mészáros
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Gábor Stelczer
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
| | - Levente Jánváry
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Zaka
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Dávid Pukancsik
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - János Fodor Md
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
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31
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Goldberg M, Whelan TJ. Accelerated Partial Breast Irradiation (APBI): Where Are We Now? CURRENT BREAST CANCER REPORTS 2020; 12:275-284. [PMID: 33101597 PMCID: PMC7568840 DOI: 10.1007/s12609-020-00384-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2020] [Indexed: 01/26/2023]
Abstract
Purpose of Review Accelerated partial breast irradiation (APBI) is an alternative approach to breast conserving therapy (BCT) where radiation (RT) is delivered over a shorter period of time compared with whole breast irradiation (WBI), resulting in improved patient convenience and cost savings. APBI can be delivered using brachytherapy, intraoperative RT, or conformal external beam radiation therapy (EBRT) techniques. In this review, the authors appraise the latest modern randomized controlled trials (RCTs) of APBI and discuss the application of the data to clinical practice. Recent Findings The OCOG-RAPID and NSABP B-39/RTOG 0413 trials recently reported long-term outcomes of APBI. The OCOG-RAPID trial delivered 38.5 Gy/10 fractions twice daily (at least 6 h apart using EBRT) or WBI and demonstrated non-inferiority of APBI compared with WBI (8-year cumulative rate of ipsilateral breast tumor recurrence (IBTR) was 3% after APBI or 2.8% after WBI, HR 1.27, 90%CI: 0.84–1.91). While acute toxicity was reduced, late toxicity and breast cosmesis were worse with APBI. The NSABP B-39 trial included higher risk patients and was unable to demonstrate equivalence between APBI (38.5 Gy/10 fractions delivered twice daily using EBRT or brachytherapy techniques) and WBI. However, 10-year IBTR rates were low: 4.6% vs. 3.9%, respectively, HR 1.22, 90%CI: 0.94–1.58. The University of Florence demonstrated low rates of local recurrence at 10 years and overall excellent breast cosmetic outcomes when APBI was delivered using EBRT to a dose of 30 Gy/5 fractions delivered on non-consecutive days. Summary Recent RCTs of APBI have shed light on important factors for the integration of APBI into clinical practice, including patient selection and treatment delivery. APBI should be limited to patients with low-risk ductal carcinoma in situ or early stage (T1) invasive ductal cancer with clear margins of excision, estrogen receptor positivity, and node negative disease. Ongoing research should focus on the optimal dose/fractionation for delivery of EBRT-based APBI.
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Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
| | - Timothy J. Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
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Pasalic D, Strom EA, Allen PK, Williamson TD, Poenisch F, Amos RA, Woodward WA, Stauder MC, Shaitelman SF, Smith BD, Perkins GH, Tereffe W, Hoffman KE. Proton Accelerated Partial Breast Irradiation: Clinical Outcomes at a Planned Interim Analysis of a Prospective Phase 2 Trial. Int J Radiat Oncol Biol Phys 2020; 109:441-448. [PMID: 32946965 DOI: 10.1016/j.ijrobp.2020.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To perform a planned interim analysis of acute (within 12 months) and late (after 12 months) toxicities and cosmetic outcomes after proton accelerated partial breast irradiation (APBI). METHODS AND MATERIALS A total of 100 patients with pTis or pT1-2 N0 (≤3cm) breast cancer status after segmental mastectomy were enrolled in a single-arm phase 2 study from 2010 to 2019. The clinically determined postlumpectomy target volume, including tumor bed surgical clips and operative-cavity soft-tissue changes seen on imaging plus a radial clinical expansion, was irradiated with passively scattered proton APBI (34 Gy in 10 fractions delivered twice daily with a minimum 6-hour interfraction interval). Patients were evaluated at protocol-specific time intervals for recurrence, physician reports of cosmetic outcomes and toxicities, and patient reports of cosmetic outcomes and satisfaction with the treatment or experience. RESULTS Median follow-up was 24 months (interquartile range [IQR], 12-43 months). Local control and overall survival were 100% at 12 and 24 months. There were no acute or late toxicities of grade 3 or higher; no patients experienced fat necrosis, fibrosis, infection, or breast shrinkage. Excellent or good cosmesis at 12 months was reported by 91% of patients and 94% of physicians; at the most recent follow-up, these were 94% and 87%, respectively. The most commonly reported late cosmetic effect was telangiectasis (17%). The total patient satisfaction rate for treatment and results at 12 and 24 months was 96% and 100%, respectively. Patients' mean time away from work was 5 days (IQR, 2-5 days), and the median out-of-pocket cost was $700 (IQR, $100-$1600). The mean left-sided heart dose was 2 cGy (range, 0.2-75 cGy), and the mean ipsilateral lung dose was 19 cGy (range, 0.2-164 cGy). CONCLUSIONS Proton APBI is a maturing treatment option with high local control, favorable intermediate-term cosmesis, high treatment satisfaction, low treatment burden, and exceptional heart and lung sparing.
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Affiliation(s)
- Dario Pasalic
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Eric A Strom
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas.
| | - Pamela K Allen
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Tyler D Williamson
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Falk Poenisch
- Department of Radiation Physics, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Richard A Amos
- Department of Radiation Physics, MD Anderson Cancer Center, The University of Texas, Houston, Texas; Department of Proton and Advanced Radiation Therapy Group, Department of Medical Physics & Biomedical Engineering, University College London, London, United Kingdom
| | - Wendy A Woodward
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Michael C Stauder
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Benjamin D Smith
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - George H Perkins
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Welela Tereffe
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
| | - Karen E Hoffman
- Department of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, Texas
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Franceschini D, Loi M, Chiola I, Arculeo S, Marzo M, Fernandes B, Masci G, Torrisi R, Tinterri C, Testori A, Santoro A, Scorsetti M. Preliminary Results of a Randomized Study on Postmenopausal Women With Early Stage Breast Cancer: Adjuvant Hypofractionated Whole Breast Irradiation Versus Accelerated Partial Breast Irradiation (HYPAB Trial). Clin Breast Cancer 2020; 21:231-238. [PMID: 33121891 DOI: 10.1016/j.clbc.2020.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The purpose of this study was to report preliminary data of a randomized phase III trial comparing hypofractionated whole breast irradiation (HWBI) and accelerated partial breast irradiation (APBI) using volumetric modulated arc therapy (VMAT). MATERIAL AND METHODS The HYPAB trial enrolled postmenopausal women with biopsy-proven infiltrating breast cancer, clinically negative axilla, single T1 to T2 tumors, who were treated with breast-conserving surgery. Patients were randomized 1:1 after surgery to HWBI (40.5 Gy whole breast, 48.0 Gy to surgical bed, 15 fractions over 3 weeks) or APBI (30 Gy delivered in 5 fractions of 6 Gy given on alternate days on the surgical bed). Cosmetic outcome was the primary end point of the study. RESULTS A total of 172 patients were enrolled. After a median follow-up of 36 months, 5 local failures and 3 locoregional failures were recorded, with no difference between the 2 treatment arms. Use of HWBI as compared with APBI was significantly correlated with increased incidence of overall (62% vs. 14%; P < .001) and grade 2 (18% vs. 1%; P < .001) acute skin toxicity. APBI was correlated with a lower incidence of overall late toxicity as compared with HWBI (18% vs. 41%; P = .001), but no significant difference was found in term of occurrence of grade 2 events (1% vs. 4%; P = NS). At comparative assessment between baseline and post-radiotherapy evaluation, impairment in cosmetic outcome was reported in 19 (11%) patients. Owing to premature closure of the study, no per-protocol comparison between the treatment arms was performed. CONCLUSION APBI with the VMAT technique is safe and feasible, with lower acute toxicity when compared with HWBI.
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Affiliation(s)
- Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy.
| | - Mauro Loi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Ilaria Chiola
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Simona Arculeo
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Marco Marzo
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Bethania Fernandes
- Pathology Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Giovanna Masci
- Medical Oncology Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Rosalba Torrisi
- Medical Oncology Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Corrado Tinterri
- Breast Surgery Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Alberto Testori
- Breast Surgery Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Armando Santoro
- Medical Oncology Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy; Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy; Humanitas University, Department of Biomedical Sciences, Milan, Italy
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Hepel JT, Leonard KL, Sha S, Graves TA, Wiggins DL, Mastras D, Pittier A, Wazer DE. Phase 2 Trial of Accelerated Partial Breast Irradiation (APBI) Using Noninvasive Image Guided Breast Brachytherapy (NIBB). Int J Radiat Oncol Biol Phys 2020; 108:1143-1149. [PMID: 32721422 DOI: 10.1016/j.ijrobp.2020.07.2312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/17/2020] [Accepted: 07/23/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Noninvasive image guided breast brachytherapy (NIBB) is a novel approach to delivery of accelerated partial breast irradiation (APBI) that may hold advantages over established techniques. NIBB is not invasive but maintains a high level of precision by using breast immobilization via breast compression and image guidance; it therefore does not require large planning tumor volume margins. We present the primary outcomes of this prospective phase 2 study (BrUOG Br-251). METHODS AND MATERIALS Eligible patients with early-stage breast cancer underwent NIBB APBI using a dose 34 Gy in 10 fractions delivered daily or twice a day. Treatment was delivered using an Ir-192 high-dose-rate source via specialized applicators. Two orthogonal treatment axes were used for each fraction. The primary endpoints were late toxicity and cosmesis assessed at 2 and 5 years. Toxicity was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events v3.0. Cosmesis was assessed using the NRG/Radiation Therapy Oncology Group scale. Ipsilateral breast tumor recurrence was defined as any recurrence or new primary in the treated breast. RESULTS Forty patients underwent protocol treatment. Median patient age was 68 years (50-92 years). Mean tumor size was 1.1 cm (0.3-3.0 cm). Among the cohort, 62.5% had invasive carcinoma and 37.5% had ductal carcinoma in situ. Thirty-nine percent elected to receive hormone therapy. No grade ≥3 late toxicities were observed at any time point. Grade 2 toxicity was 5% and 10% at 2 and 5 years, respectively. Telangiectasia grade 1 and 2 occurred in 27.5% and 5%, respectively. Breast separation of >7 cm was associated with telangiectasia (P < .01). The rate of good to excellent cosmetic outcome was 95% at 2 years and 100% at 5 years. With a median follow-up of 68 months, the actuarial 5-year freedom from ipsilateral breast tumor recurrence was 93.3% (±4.8%), and overall survival was 93.7% (±4.4%). CONCLUSIONS NIBB to deliver APBI is well tolerated with a low incidence of significant late toxicity and has favorable cosmetic outcomes. Continued evaluation of the NIBB APBI technique in a larger cohort is warranted.
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Affiliation(s)
- Jaroslaw T Hepel
- Department of Radiation Oncology, Rhode Island Hospital, Brown University, Providence, Rhode Island; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, Massachusetts.
| | - Kara L Leonard
- Department of Radiation Oncology, Rhode Island Hospital, Brown University, Providence, Rhode Island; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, Massachusetts
| | - Sandra Sha
- Department of Radiation Oncology, Watson Clinic, Lakeland, Florida
| | - Theresa A Graves
- Department of Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island
| | - Doreen L Wiggins
- Department of Surgery, Rhode Island Hospital, Brown University, Providence, Rhode Island
| | - Dean Mastras
- Department of Radiation Oncology, Tacoma Valley Radiation, Tacoma, Washington
| | - Ann Pittier
- Department of Radiation Oncology, Tacoma Valley Radiation, Tacoma, Washington
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- Brown University, Providence, Rhode Island
| | - David E Wazer
- Department of Radiation Oncology, Rhode Island Hospital, Brown University, Providence, Rhode Island; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, Massachusetts
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35
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Mészáros N, Smanykó V, Major T, Stelczer G, Jánváry L, Kovács E, Mária B, Zaka Z, Pukancsik D, Takácsi-Nagy Z, Polgár C. Implementation of Stereotactic Accelerated Partial Breast Irradiation Using Cyber-Knife - Technical Considerations and Early Experiences of a Phase II Clinical Study. Pathol Oncol Res 2020; 26:2307-2313. [PMID: 32472440 PMCID: PMC7471183 DOI: 10.1007/s12253-020-00821-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 05/12/2020] [Indexed: 12/25/2022]
Abstract
To report the implementation, dosimetric results of and early experiences with stereotactic accelerated partial breast irradiation (SAPBI) following breast conserving surgery (BCS) for postmenopausal low-risk St I-II invasive breast cancer (IBC) patients. Between November 2018 and August 2019, 27 patients were registered in our phase II prospective study. SAPBI was performed with Cyber-Knife (CK) M6 machine, in 4 daily fractions of 6.25 Gy to a total dose of 25 Gy. Respiratory movements were followed with implanted gold markers and Synchrony system. Corrections for patient displacement and respiratory movement during treatment were performed with the robotic arm. Early side effects, cosmetic results, and dosimetric parameters were assessed. The average volume of the surgical cavity, clinical target volume (CTV), and planning target volume (PTV_EVAL) were 8.1 cm3 (range: 1.75–27.3 cm3), 55.3 cm3 (range: 26.2–103.5 cm3), and 75.7 cm3 (range: 40–135.4 cm3), respectively. The mean value of the PTV_eval/whole breast volume ratio was 0.09 (range: 0.04–0.19). No grade 2 or worst acute side-effect was detected. Grade 1 (G1) erythema occurred in 6 (22.2%) patients, while G1 oedema was reported by 3 (11.1%) cases. G1 pain was observed in 1 (3.4%) patient. Cosmetic result were excellent in 17 (62.9%) and good in 10 (37.1%) patients. SAPBI with CK is a suitable and practicable technique for the delivery of APBI after BCS for low-risk, St. I-II. IBC. Our early findings are encouraging, CK-SAPBI performed with four daily fractions is convenient and perfectly tolerated by the patients.
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Affiliation(s)
- Norbert Mészáros
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary. .,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary.
| | - Viktor Smanykó
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary.,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Gábor Stelczer
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Levente Jánváry
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Eszter Kovács
- Department of Radiology, National Institute of Oncology, Budapest, Hungary
| | - Bahéri Mária
- Department of Radiology, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Zaka
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary
| | - Dávid Pukancsik
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary.,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, Budapest, H-1122, Hungary.,Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
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36
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Kennedy WR, Roach MC, Thomas MA, Ochoa L, Altman MB, Hernandez-Aya LF, Cyr AE, Margenthaler JA, Zoberi I. Long-Term Outcomes with 3-Dimensional Conformal External Beam Accelerated Partial Breast Irradiation. Pract Radiat Oncol 2020; 10:e128-e135. [DOI: 10.1016/j.prro.2019.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/29/2019] [Accepted: 09/06/2019] [Indexed: 01/20/2023]
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37
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Lee WH, Chang JS, Kim MJ, Park VY, Yoon JH, Kim SY, Kim JY, Park HS, Kim SI, Cho YU, Park BW, Kim YB. First Experience in Korea of Stereotactic Partial Breast Irradiation for Low-Risk Early-Stage Breast Cancer. Front Oncol 2020; 10:672. [PMID: 32411612 PMCID: PMC7201053 DOI: 10.3389/fonc.2020.00672] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 04/09/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose: Accelerated partial breast irradiation (A-PBI) in Korean women has been considered impracticable, owing to small breast volume and lack of high-precision radiotherapy experience. We present the first experience of stereotactic-PBI (S-PBI) with CyberKnife M6 to investigate feasibility of use and early toxicities in Korean women with early breast cancers. Materials and Methods: A total of 104 breasts receiving S-PBI at our institution between September 2017 and October 2018 were reviewed. Patients were selected based on the American Society for Radiation Oncology (ASTRO), American Brachytherapy Society, American Society of Breast Surgeons, and Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology guidelines. A dose of 30 Gy in 5 fractions (NCT01162200) was used. Gold fiducials were routinely inserted near the tumor bed for tracking. Constraints regarding organs-at-risk followed the NSABP-B39/RTOG 0413 protocol. Results: Median follow-up was for 13 months. Patients were categorized as “suitable” (71.2%) or “cautionary” (28.8%) according to 2017 the ASTRO guidelines. No tracking failure of inserted gold fiducials occurred. Median planning target volume (PTV) and PTV-to-whole breast volume ratio was 73.6 mL (interquartile range, 58.8–103.9 mL) and 17.0% (13.3–19.1%), respectively. Median PTV V95%, PTV Dmax, and ipsilateral breast V50% were 97.8% (96.2–98.8%), 105.3% (104.2–106.4%), and 35.5% (28.3–39.8%), respectively. No immediate post-S-PBI toxicity ≥ grade 2 was reported, except grade 2 induration in three breasts. All patients remain disease-free to date. Conclusion: The first use of S-PBI in Korean women was feasible and safe for selected early breast cancer. Based on these results, we have initiated a prospective study (NCT03568981) to test S-PBI in whole-breast irradiation for low-risk early breast cancer.
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Affiliation(s)
- Won Hee Lee
- Department of Radiation Oncology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Jung Kim
- Department of Radiology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Vivian Youngjean Park
- Department of Radiology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung Hyun Yoon
- Department of Radiology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Se Young Kim
- Department of Radiation Oncology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jee Ye Kim
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyung Seok Park
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Il Kim
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Up Cho
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeong Woo Park
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
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38
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Avanzo M, Pirrone G, Vinante L, Caroli A, Stancanello J, Drigo A, Massarut S, Mileto M, Urbani M, Trovo M, El Naqa I, De Paoli A, Sartor G. Electron Density and Biologically Effective Dose (BED) Radiomics-Based Machine Learning Models to Predict Late Radiation-Induced Subcutaneous Fibrosis. Front Oncol 2020; 10:490. [PMID: 32373520 PMCID: PMC7186445 DOI: 10.3389/fonc.2020.00490] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/18/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose: to predict the occurrence of late subcutaneous radiation induced fibrosis (RIF) after partial breast irradiation (PBI) for breast carcinoma by using machine learning (ML) models and radiomic features from 3D Biologically Effective Dose (3D-BED) and Relative Electron Density (3D-RED). Methods: 165 patients underwent external PBI following a hypo-fractionation protocol consisting of 40 Gy/10 fractions, 35 Gy/7 fractions, and 28 Gy/4 fractions, for 73, 60, and 32 patients, respectively. Physicians evaluated toxicity at regular intervals by the Common Terminology Adverse Events (CTAE) version 4.0. RIF was assessed every 3 months after the completion of radiation course and scored prospectively. RIF was experienced by 41 (24.8%) patients after average 5 years of follow up. The Hounsfield Units (HU) of the CT-images were converted into relative electron density (3D-RED) and Dose maps into Biologically Effective Dose (3D-BED), respectively. Shape, first-order and textural features of 3D-RED and 3D-BED were calculated in the planning target volume (PTV) and breast. Clinical and demographic variables were also considered (954 features in total). Imbalance of the dataset was addressed by data augmentation using ADASYN technique. A subset of non-redundant features that best predict the data was identified by sequential feature selection. Support Vector Machines (SVM), ensemble machine learning (EML) using various aggregation algorithms and Naive Bayes (NB) classifiers were trained on patient dataset to predict RIF occurrence. Models were assessed using sensitivity and specificity of the ML classifiers and the area under the receiver operator characteristic curve (AUC) of the score functions in repeated 5-fold cross validation on the augmented dataset. Results: The SVM model with seven features was preferred for RIF prediction and scored sensitivity 0.83 (95% CI 0.80-0.86), specificity 0.75 (95% CI 0.71-0.77) and AUC of the score function 0.86 (0.85-0.88) on cross-validation. The selected features included cluster shade and Run Length Non-uniformity of breast 3D-BED, kurtosis and cluster shade from PTV 3D-RED, and 10th percentile of PTV 3D-BED. Conclusion: Textures extracted from 3D-BED and 3D-RED in the breast and PTV can predict late RIF and may help better select patient candidates to exclusive PBI.
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Affiliation(s)
- Michele Avanzo
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Giovanni Pirrone
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Angela Caroli
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Annalisa Drigo
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Samuele Massarut
- Breast Surgery Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Mario Mileto
- Breast Surgery Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Martina Urbani
- Department of Radiology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Marco Trovo
- Department of Radiation Oncology, Udine General Hospital, Udine, Italy
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
| | - Antonino De Paoli
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Giovanna Sartor
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
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La Rocca E, Lozza L, D' Ippolito E, Dispinzieri M, Giandini C, Bonfantini F, Valdagni R, Folli S, Pignoli E, Di Cosimo S, De Santis MC. VMAT partial-breast irradiation: acute toxicity of hypofractionated schedules of 30 Gy in five daily fractions. Clin Transl Oncol 2020; 22:1802-1808. [PMID: 32128672 DOI: 10.1007/s12094-020-02319-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 02/08/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE To report acute toxicities in breast cancer (BC) patients (pts) recruited in a prospective trial and treated with accelerated partial-breast irradiation (APBI) using Volumetric Modulated Arc Therapy (VMAT) delivered with a hypofractionated schedule. METHODS From March 2014 to June 2019, pts with early-stage BC (Stage I), who underwent breast conservative surgery (BCS), were recruited in a prospective study started at the National Cancer Institute of Milan. Pts received APBI with a hypofractionated schedule of 30 Gy in five daily fractions. Radiotherapy treatment (RT) was delivered using VMAT. Acute toxicity was assessed according to RTOG/EORTC criteria at the end of RT. RESULTS Between March 2014 and June 2019, 151 pts were enrolled in this study. 79 Pts had right-side and 72 had left-side breast cancer. Median age was 69 (range 43-92). All pts presented with pathological stage IA BC, molecular classification was Luminal A in 128/151 (85%) and Luminal B in 23/151 (15%) cases. Acute toxicity, assessed at the end of RT, consisted of G1 erythema in 37/151 (24. 5%) pts and skin toxicities higher than G1, did not occur. Fibrosis G1 and G2 were reported in 41/151 (27. 1%) pts and in 2/151 pts (1. 3%), respectively. Edema G1 occurred in 8/151 (5. 3%) pts and asthenia G1 occurred in 1/151 (0. 6%) pts. CONCLUSIONS APBI with VMAT proved to be feasible and can be a valid alternative treatment option after BCS in selected early breast cancer pts according to ASTRO guidelines. A longer follow-up is needed to assess late toxicity.
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Affiliation(s)
- E La Rocca
- Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi Di Milan, Milano, Italy
| | - L Lozza
- Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - E D' Ippolito
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - M Dispinzieri
- Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - C Giandini
- Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi Di Milan, Milano, Italy
| | - F Bonfantini
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,Radiotherapy and Oncology Unit, ASST Bergamo Ovest, Treviglio, Italy
| | - R Valdagni
- Department of Oncology and Hemato-Oncology, Università Degli Studi Di Milan, Milano, Italy.,Radiation Oncology 1 and Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - S Folli
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - E Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - S Di Cosimo
- Biomarker Unit, Department of Applied Research and Technological Development (DRAST), Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - M C De Santis
- Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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Yadav BS, Loganathan S, Sharma SC, Singh R, Dahiya D. Comparison of Toxicity and Cosmetic Outcomes After Accelerated Partial Breast Irradiation or Whole Breast Irradiation Using 3-Dimensional Conformal External Beam Radiation Therapy. Adv Radiat Oncol 2020; 5:171-179. [PMID: 32280816 PMCID: PMC7136642 DOI: 10.1016/j.adro.2019.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/30/2019] [Accepted: 09/18/2019] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To compare rates of acute and late skin toxicities and cosmetic outcomes after accelerated partial breast irradiation (APBI) or whole breast irradiation (WBI) using 3-dimensional conformal external beam radiation therapy in women with breast cancer after breast conservation surgery (BCS). METHODS AND MATERIALS Women >35 years of age with invasive or noninvasive breast cancer ≤4 cm treated by BCS were randomized to 3D-CRT APBI (34 Gy/10 fractions/5 days) or WBI (40 Gy/16 fractions/3 weeks ± boost irradiation). The primary outcome was ipsilateral breast tumor recurrence. Important secondary outcomes were skin toxicities using Radiation Therapy Oncology Group scores, Late Effects Normal Tissue Task Force and Subjective, Objective, Management, Analytic scales, and adverse cosmetic outcome. This interim analysis focuses on the secondary endpoints of radiation toxicities and cosmesis. Patient and tumor characteristics and rates of adverse cosmetic outcomes and skin toxicities were compared using Fisher exact tests. All statistical tests were 2 sided, with P < .05 considered statistically significant. RESULTS Between June 2011 and December 2015, 133 women with breast cancer were randomized to 3D-CRT APBI or WBI. Patient and tumor characteristics were balanced between the 2 arms. Median follow-up was 60 months (range, 12-93 months). Grade 4 late toxicity was not seen in either of the treatment arms, and grade 3 toxicity was very low for each endpoint assessed in both the groups. The rates of grade ≥2 acute dermatitis were 8% and 15%, respectively, for APBI and WBI (P = .18). Rates of grade ≥1 late radiation toxicities were higher in the WBI arm compared with the APBI arm for breast shrinkage (P = .008), pigmentation (P = .028), fibrosis (P = .040), induration (P = .048), and edema (P = .33). Adverse cosmesis at last follow-up was significantly higher in patients treated with WBI: 33% compared with 6% with APBI (P < .001). CONCLUSIONS In women with breast cancer after BCS, APBI was associated with better cosmetic outcome and fewer late radiation toxicities than WBI.
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Affiliation(s)
- Budhi Singh Yadav
- Department of Radiation Oncology, Regional Cancer Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sofia Loganathan
- Department of Radiation Oncology, Government Medical College, Trichy, Tamilnadu, India
| | - Suresh C. Sharma
- Department of Radiation Oncology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Maharishi Markandeshwar University, Mullana (Ambala), India
| | - Rajinder Singh
- Department of General Surgery, Chautani Medical Centre, Chandigarh, India
| | - Divya Dahiya
- Department of General Surgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Bosma SCJ, Leij F, Vreeswijk S, Maaker MD, Wesseling J, Vijver MVD, Scholten A, Rivera S, Bourgier C, Auzac G, Foukakis T, Lekberg T, Bongard D, Loo C, Rutgers E, Bartelink H, Elkhuizen PHM. Five-Year Results of the Preoperative Accelerated Partial Breast Irradiation (PAPBI) Trial. Int J Radiat Oncol Biol Phys 2020; 106:958-967. [PMID: 31987957 DOI: 10.1016/j.ijrobp.2019.12.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE In this multicenter phase 2 feasibility study, we investigated the impact of preoperative accelerated partial breast irradiation (PAPBI) on local control, breast fibrosis, and cosmetic outcome. METHODS AND MATERIALS Women aged >60 years with an invasive, unifocal (mammography and magnetic resonance imaging), nonlobular adenocarcinoma of the breast were treated with PAPBI. Six weeks after radiation therapy, a wide local excision was performed. Radiation therapy consisted of 10 × 4 Gy (2010-2013) or 5 × 6 Gy (after 2013) to the tumor (gross target volume) with a 25 mm margin (20 mm from gross target volume to clinical target volume, 5 mm planning target volume). RESULTS One hundred thirty-three patients treated between 2010 and 2016 were analyzed with a median follow-up of 5.0 years (0.9-8.8 years). Seventy-eight (59%) patients were treated with 10 × 4 Gy in 2 weeks and 55 (41%) patients with 5 × 6 Gy in 1 week. Eighteen postoperative complications (14%) occurred in 15 patients (11%). The proportion of patients with no to mild fibrosis in the treated part of the breast at 2 years and later time points was around 90%. Cosmesis improved over time in several patients: excellent to good cosmetic score as rated by the physician was 68% at 6 months and 92% at 5 years. Seventy-seven percent (6 months) to 82% (5 years) of patients were "satisfied" or "very satisfied" with their cosmetic outcome. Three recurrences were detected in the biopsy track and 1 recurrence in the ipsilateral breast. CONCLUSIONS PAPBI is a feasible method with a low postoperative complication rate, limited fibrosis, and good to excellent cosmetic outcome. The local recurrence rate was 3% at 5 years; however, no local recurrences were observed since removal of the needle biopsy track.
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Affiliation(s)
- Sophie C J Bosma
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Femke Leij
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sandra Vreeswijk
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel de Maaker
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Astrid Scholten
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Celine Bourgier
- Department of Radiation Oncology, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | - Guillaume Auzac
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Theodoros Foukakis
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Lekberg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Desiree Bongard
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Claudette Loo
- Department of Radiology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Emiel Rutgers
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Harry Bartelink
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands.
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42
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Rahimy E, Weidhaas J, Wei W, Lannin D, Horowitz N, Higgins S, Wilson LD, Knowlton C, Moran MS, Young MR, Killelea B, Chagpar A, Yeboa DN, Zelterman D, Evans S. Patient-Reported Outcomes and Cosmesis in a Feasibility Study of 4-Dimensional Simulated Image Guided Accelerated Partial Breast Irradiation. Pract Radiat Oncol 2019; 9:e257-e265. [DOI: 10.1016/j.prro.2019.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 01/26/2019] [Accepted: 01/29/2019] [Indexed: 02/05/2023]
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Shah C, Vicini F. Accelerated partial breast irradiation-Redefining the treatment target for women with early stage breast cancer. Breast J 2019; 25:408-417. [PMID: 30950133 DOI: 10.1111/tbj.13241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/07/2018] [Accepted: 06/19/2018] [Indexed: 01/19/2023]
Abstract
Following breast conserving surgery, the standard of care has been to deliver adjuvant radiation therapy directed to the whole breast (WBI) over a period of 3-7 weeks. Over the past decade, increasing data have supported the concept that treatment to the whole breast may not be required in selected patients, allowing for the emergence of partial breast irradiation (PBI). Multiple randomized trials with 5-10 years of follow-up have been published documenting the safety and efficacy associated with PBI using multiple techniques. Questions that remain to be answered include (a) what is the optimal PBI technique for each clinical scenario, (b) are there additional patients that can be effectively managed with PBI approaches, and (c) are there different techniques/dose schedules that allow for further reduction in treatment duration and/or toxicities? Partial breast irradiation represents a standard approach for appropriately selected patients. PBI provides comparable clinical outcomes to WBI while allowing for a reduction in the duration treatment and the potential for reduced toxicities. Future studies may also help to better define which patients require no radiation, PBI, hypofractionated WBI or conventional WBI, based upon patient, clinical, pathologic features as well as potentially using tumor genetics.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Frank Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, Michigan
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Vinante L, Avanzo M, Furlan C, Fiorica F, Perin T, Militello L, Spazzapan S, Berretta M, Jena R, Stancanello J, Piccoli E, Mileto M, Micheli E, Roncadin M, Massarut S, Trovò M. Ten daily fractions for partial breast irradiation. Long-term results of a prospective phase II trial. Breast J 2019; 25:243-249. [PMID: 30714257 DOI: 10.1111/tbj.13195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/14/2018] [Accepted: 03/16/2018] [Indexed: 11/30/2022]
Abstract
Partial breast irradiation (PBI) is an effective adjuvant treatment after breast conservative surgery for selected early-stage breast cancer patients. However, the best fractionation scheme is not well defined. Hereby, we report the 5-year clinical outcome and toxicity of a phase II prospective study of a novel regimen to deliver PBI, which consists in 40 Gy delivered in 10 daily fractions. Patients with early-stage (pT1-pT2, pN0-pN1a, M0) invasive breast cancer were enrolled after conservative surgery. The minimum age at diagnosis was 60 years old. PBI was delivered with 3D-conformal radiotherapy technique with a total dose of 40 Gy, fractionated in 10 daily fractions (4 Gy/fraction). Eighty patients were enrolled. The median follow-up was 67 months. Five-year local control (LC), disease-free survival (DFS), and overall survival (OS) were 95%, 91%, and 96%, respectively. Grade I and II subcutaneous fibrosis were documented in 23% and 5% of cases. No grade III late toxicity was observed. PBI delivered in 40 Gy in 10 daily fractions provided good clinical results and was a valid radiotherapy option for early-stage breast cancer patients.
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Affiliation(s)
- Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Michele Avanzo
- Division of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Carlo Furlan
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy.,Department of Radiation Oncology, Belluno General Hospital, Belluno, Italy
| | - Francesco Fiorica
- Department of Radiation Oncology, University Hospital S. Anna, Ferrara, Italy
| | - Tiziana Perin
- Department of Pathology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Loredana Militello
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Simon Spazzapan
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Massimiliano Berretta
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Rajesh Jena
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Erica Piccoli
- Breast Surgery Unit, Department of Oncology and Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Mario Mileto
- Breast Surgery Unit, Department of Oncology and Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Elvia Micheli
- Department of General Surgery, Pordenone General Hospital, Pordenone, Italy
| | - Mario Roncadin
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Samuele Massarut
- Breast Surgery Unit, Department of Oncology and Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Marco Trovò
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy.,Department of Radiation Oncology, Udine General Hospital, Udine, Italy
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Bennion NR, Baine M, Granatowicz A, Wahl AO. Accelerated partial breast radiotherapy: a review of the literature and future directions. Gland Surg 2018; 7:596-610. [PMID: 30687631 DOI: 10.21037/gs.2018.11.05] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Breast conservation therapy exemplifies the tailoring of medicine in the care of patients with cancer. Akin to improvements in surgical approaches, accelerated partial breast irradiation (APBI) tailors the treatment volume and duration to the needs of well selected patients. Here, we examine the evidence supporting APBI as well as the lessons in patient selection, dose and delivery techniques. Examination of historical techniques and their associated outcomes will support more correct patient selection and treatment delivery in an era where we await the reports of several large prospective trials.
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Affiliation(s)
- Nathan R Bennion
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael Baine
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Andrew O Wahl
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
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Henke LE, Contreras JA, Green OL, Cai B, Kim H, Roach MC, Olsen JR, Fischer-Valuck B, Mullen DF, Kashani R, Thomas MA, Huang J, Zoberi I, Yang D, Rodriguez V, Bradley JD, Robinson CG, Parikh P, Mutic S, Michalski J. Magnetic Resonance Image-Guided Radiotherapy (MRIgRT): A 4.5-Year Clinical Experience. Clin Oncol (R Coll Radiol) 2018; 30:720-727. [PMID: 30197095 PMCID: PMC6177300 DOI: 10.1016/j.clon.2018.08.010] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/19/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
Abstract
AIMS Magnetic resonance image-guided radiotherapy (MRIgRT) has been clinically implemented since 2014. This technology offers improved soft-tissue visualisation, daily imaging, and intra-fraction real-time imaging without added radiation exposure, and the opportunity for adaptive radiotherapy (ART) to adjust for anatomical changes. Here we share the longest single-institution experience with MRIgRT, focusing on trends and changes in use over the past 4.5 years. MATERIALS AND METHODS We analysed clinical information, including patient demographics, treatment dates, disease sites, dose/fractionation, and clinical trial enrolment for all patients treated at our institution using MRIgRT on a commercially available, integrated 0.35 T MRI, tri-cobalt-60 device from 2014 to 2018. For each patient, factors including disease site, clinical rationale for MRIgRT use, use of ART, and proportion of fractions adapted were summated and compared between individual years of use (2014-2018) to identify shifts in institutional practice patterns. RESULTS Six hundred and forty-two patients were treated with 666 unique treatment courses using MRIgRT at our institution between 2014 and 2018. Breast cancer was the most common disease, with use of cine MRI gating being a particularly important indication, followed by abdominal sites, where the need for cine gating and use of ART drove MRIgRT use. One hundred and ninety patients were treated using ART in 1550 fractions, 67.6% (1050) of which were adapted. ART was primarily used in cancers of the abdomen. Over time, breast and gastrointestinal cancers became increasingly dominant for MRIgRT use, hypofractionated treatment courses became more popular, and gastrointestinal cancers became the principal focus of ART. DISCUSSION MRIgRT is widely applicable within the field of radiation oncology and new clinical uses continue to emerge. At our institution to date, applications such as ART for gastrointestinal cancers and accelerated partial breast irradiation (APBI) for breast cancer have become dominant indications, although this is likely to continue to evolve.
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Affiliation(s)
- L E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J A Contreras
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - O L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - B Cai
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - H Kim
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - M C Roach
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J R Olsen
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - B Fischer-Valuck
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - D F Mullen
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - R Kashani
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - M A Thomas
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J Huang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - I Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - D Yang
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - V Rodriguez
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J D Bradley
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - C G Robinson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - P Parikh
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - S Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - J Michalski
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA.
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Lischalk JW, Chen H, Repka MC, Campbell LD, Obayomi-Davies O, Kataria S, Kole TP, Rudra S, Collins BT. Definitive hypofractionated radiation therapy for early stage breast cancer: Dosimetric feasibility of stereotactic ablative radiotherapy and proton beam therapy for intact breast tumors. Adv Radiat Oncol 2018; 3:447-457. [PMID: 30202812 PMCID: PMC6128030 DOI: 10.1016/j.adro.2018.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/18/2018] [Accepted: 05/10/2018] [Indexed: 12/31/2022] Open
Abstract
Purpose Few definitive treatment options exist for elderly patients diagnosed with early stage breast cancer who are medically inoperable or refuse surgery. Historical data suggest very poor local control with hormone therapy alone. We examined the dosimetric feasibility of hypofractionated radiation therapy using stereotactic ablative radiotherapy (SABR) and proton beam therapy (PBT) as a means of definitive treatment for early stage breast cancer. Methods and Materials Fifteen patients with biopsy-proven early stage breast cancer with a clinically visible tumor on preoperative computed tomography scans were identified. Gross tumor volumes were contoured and correlated with known biopsy-proven malignancy on prior imaging. Treatment margins were created on the basis of set-up uncertainty and image guidance capabilities of the three radiation modalities analyzed (3-dimensional conformal radiation therapy [3D-CRT], SABR, and PBT) to deliver a total dose of 50 Gy in 5 fractions. Dose volume histograms were analyzed and compared between treatment techniques. Results The median planning target volume (PTV) for SABR, PBT, and 3-dimensional CRT was 11.91, 21.03, and 45.08 cm3, respectively, and were significantly different (P < .0001) between treatment modalities. Overall target coverage of gross tumor and clinical target volumes was excellent with all three modalities. Both SABR and PBT demonstrated significant dosimetric improvements, each in its own unique manner, relative to 3D-CRT. Dose constraints to normal structures including ipsilateral/contralateral breast, bilateral lungs, and heart were all consistently achieved using SABR and PBT. However, skin or chest wall dose constraints were exceeded in some cases for both SABR and PBT plans and was dictated by the anatomic location of the tumor. Conclusions Definitive hypofractionated radiation therapy using SABR and PBT appears to be dosimetrically feasible for the treatment of early stage breast cancer. The anatomical location of the tumor relative to the skin and chest wall appears to be the primary limiting dosimetric factor.
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Affiliation(s)
- Jonathan W Lischalk
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia
| | - Hao Chen
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia
| | - Michael C Repka
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia
| | - Lloyd D Campbell
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia
| | - Olusola Obayomi-Davies
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia
| | - Shaan Kataria
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia
| | - Thomas P Kole
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia
| | - Sonali Rudra
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia
| | - Brian T Collins
- Department of Radiation Medicine, Georgetown University Hospital, Washington, District of Columbia
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Hepel JT, Yashar C, Leonard KL, Einck JP, Sha S, DiPetrillo T, Wiggins D, Graves TA, Edmonson D, Wazer DE. Five fraction accelerated partial breast irradiation using noninvasive image-guided breast brachytherapy: Feasibility and acute toxicity. Brachytherapy 2018; 17:825-830. [DOI: 10.1016/j.brachy.2018.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/08/2018] [Accepted: 05/23/2018] [Indexed: 11/25/2022]
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49
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Stecklein SR, Shaitelman SF, Babiera GV, Bedrosian I, Black DM, Ballo MT, Arzu I, Strom EA, Reed VK, Dvorak T, Smith BD, Woodward WA, Hoffman KE, Schlembach PJ, Kirsner SM, Nelson CL, Yang J, Guerra W, Dibaj S, Bloom ES. Prospective Comparison of Toxicity and Cosmetic Outcome After Accelerated Partial Breast Irradiation With Conformal External Beam Radiotherapy or Single-Entry Multilumen Intracavitary Brachytherapy. Pract Radiat Oncol 2018; 9:e4-e13. [PMID: 30125673 DOI: 10.1016/j.prro.2018.08.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/26/2018] [Accepted: 08/07/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aimed to prospectively characterize toxicity and cosmesis after accelerated partial breast irradiation (APBI) with 3-dimensional conformal radiation therapy (CRT) or single-entry, multilumen, intracavitary brachytherapy. METHODS AND MATERIALS A total of 281 patients with pTis, pT1N0, or pT2N0 (≤3.0 cm) breast cancer treated with segmental mastectomy were prospectively enrolled from December 2008 through August 2014. APBI was delivered using 3-dimensional CRT (n = 29) or with SAVI (n = 176), Contura (n = 56), or MammoSite (n = 20) brachytherapy catheters. Patients were evaluated at protocol-specified intervals, at which time the radiation oncologist scored cosmetic outcome, toxicities, and recurrence status using a standardized template. RESULTS The median follow-up time is 41 months. Grade 1 seroma and fibrosis were more common with brachytherapy than with 3-dimensional CRT (50.4% vs 3.4% for seroma; P < .0001 and 66.3% vs 44.8% for fibrosis; P = .02), but grade 1 edema was more common with 3-dimensional CRT than with brachytherapy (17.2% vs 5.6%; P = .04). Grade 2 to 3 pain was more common with 3-dimensional CRT (17.2% vs 5.2%; P = .03). Actuarial 5-year rates of fair or poor radiation oncologist-reported cosmetic outcome were 9% for 3-dimensional CRT and 24% for brachytherapy (P = .13). Brachytherapy was significantly associated with inferior cosmesis on mixed model analysis (P = .003). Significant predictors of reduced risk of adverse cosmetic outcome after brachytherapy were D0.1cc (skin) ≤102%, minimum skin distance >5.1 mm, dose homogeneity index >0.54, and volume of nonconformance ≤0.89 cc. The 5-year ipsilateral breast recurrence was 4.3% for brachytherapy and 4.2% for 3-dimensional CRT APBI patients (P = .95). CONCLUSIONS Brachytherapy APBI is associated with higher rates of grade 1 fibrosis and seroma than 3-dimensional CRT but lower rates of grade 1 edema and grade 2 to 3 pain than 3-dimensional CRT. Rates of radiation oncologist-reported fair or poor cosmetic outcomes are higher with brachytherapy. We identified dosimetric parameters that predict reduced risk of adverse cosmetic outcome after brachytherapy-based APBI. Ipsilateral breast recurrence was equivalent for brachytherapy and 3-dimensional CRT.
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Affiliation(s)
- Shane R Stecklein
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Gildy V Babiera
- Department of Breast Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Isabelle Bedrosian
- Department of Breast Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Dalliah M Black
- Department of Breast Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Matthew T Ballo
- Department of Radiation Oncology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Isadora Arzu
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Eric A Strom
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Valerie K Reed
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Tomas Dvorak
- Department of Radiation Oncology, UFHealth Cancer Center/Orlando Health, Orlando, Florida
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Wendy A Woodward
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Karen E Hoffman
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Pamela J Schlembach
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Steve M Kirsner
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Christopher L Nelson
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - William Guerra
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Shiva Dibaj
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth S Bloom
- Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas.
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Acute toxicity of intraoperative radiotherapy and external beam-accelerated partial breast irradiation in elderly breast cancer patients. Breast Cancer Res Treat 2018; 169:549-559. [PMID: 29460031 PMCID: PMC5953978 DOI: 10.1007/s10549-018-4712-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/03/2018] [Indexed: 12/27/2022]
Abstract
Background and purpose We investigated the acute toxicity of accelerated partial breast irradiation using external beam (EB-APBI) or intraoperative radiotherapy (IORT) techniques in elderly breast cancer patients. Materials and methods Women ≥ 60 years with unifocal breast tumors of ≤ 30 mm were eligible for this prospective multi-center cohort study. IORT was applied with electrons following lumpectomy (23.3 Gy). EB-APBI was delivered using 3D-CRT or IMRT in 10 daily fractions of 3.85 Gy within 6 weeks after surgery. Acute toxicity was scored using the CTCAE v3.0 at 3 months after treatment. Patient-reported symptoms were analyzed using visual analogue scales (VAS) for pain and fatigue (scale 0–10), and single items from the EORTC QLQ-C30 and Breast Cancer questionnaires. Results In total, 267 (IORT) and 206 (EB-APBI) patients were available for toxicity analysis. More patients experienced ≥ grade 2 CTCAE acute toxicity in the IORT group (10.4% IORT and 4.9% EB-APBI; p = 0.03); grade 3 toxicity was low (3.3% IORT and 1.5% EB-APBI; ns); and no grade 4 toxicity occurred. EB-APBI patients experienced less fatigue direct postoperatively (EORTC p < 0.00, VAS p < 0.00). After 3 months only pain, according to the VAS scale, was significantly worse in the EB-APBI group (p < 0.00). Conclusion Acute toxicity after IORT and EB-APBI treatment is acceptable.
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