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1
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Leonardi MC, Arculeo S, Frassoni S, Zerella MA, Gerardi MA, Fodor C, Veronesi P, Galimberti VE, Magnoni F, Milovanova E, Rojas DP, Dicuonzo S, Morra A, Zaffaroni M, Vincini MG, Cattani F, Bagnardi V, Orecchia R, Jereczek-Fossa BA. Hypofractionated Partial Breast Reirradiation in the Conservative Retreatment of Breast Cancer Local Recurrence. Pract Radiat Oncol 2025; 15:31-47. [PMID: 39069002 DOI: 10.1016/j.prro.2024.07.003] [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: 04/23/2024] [Revised: 06/24/2024] [Accepted: 07/02/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE To evaluate the outcome of partial breast reirradiation (re-PBI) with intensity modulated radiation therapy using a hypofractionated scheme for breast cancer (BC) local relapse (LR) operated on with repeat breast-conservative surgery. METHODS AND MATERIALS Intensity modulated radiation therapy-based re-PBI was performed using either helical or step-and-shoot modality to deliver 37.05 Gy in 13 fractions in 2.5 weeks. Cumulative incidence of second LR, toxicity, disease-free survival (DFS), BC-specific survival, and overall survival were evaluated. RESULTS Between May 2012 and May 2021, 70 patients had re-PBI. The median follow-up (FU) was 6.3 years (quartiles 1-3, 4.0-8.1.). The median age at first LR was 62 years. The median primary BC first LR interval was 12.4 years (range, 1.6-26.7 years). Luminal A-like first LR accounted for 41% of the cases, and the median size was 0.8 cm. During FU, 18 (26%) patients showed a subsequent event: 3 second LRs (corresponding to an 8-year cumulative rate of 4%), 3 regional nodal recurrences, 7 distant metastases, and 5 other primary tumors. At 8 years, DFS, BC-specific survival, and overall survival were 76%, 90%, and 90%, respectively. At multivariate analysis, grade 3 and extensive intraductal components were independent predictors for DFS. For 51 and 46 patients, chronic toxicity and cosmesis were evaluated, respectively: 4% had grade 3 fibrosis, and cosmesis was deemed good/excellent in just >60% of the cases. CONCLUSIONS Re-PBI after repeat breast-conservative surgery represents a feasible alternative to mastectomy with regard to local control, showing an acceptable toxicity profile. A long-term FU is crucial to better understand the pattern of relapse and consolidate the position of re-PBI in clinical practice.
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Affiliation(s)
| | - Simona Arculeo
- Division of Radiotherapy, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | | | | | - Cristiana Fodor
- Division of Radiotherapy, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | - Paolo Veronesi
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Division of Senology, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | | | - Francesca Magnoni
- Division of Senology, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | - Ekaterina Milovanova
- Division of Radiotherapy, European Institute of Oncology, IEO IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | | | - Samantha Dicuonzo
- Division of Radiotherapy, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | - Anna Morra
- Division of Radiotherapy, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | - Mattia Zaffaroni
- Division of Radiotherapy, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | - Maria Giulia Vincini
- Division of Radiotherapy, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology IRCCS, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiotherapy, European Institute of Oncology, IEO IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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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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Ning J, Cheng G, Wu N. A systematic review on the techniques, long-term outcomes, and complications of partial breast irradiation after breast-conserving surgery for early-stage breast cancer. Sci Rep 2024; 14:22283. [PMID: 39333210 PMCID: PMC11436892 DOI: 10.1038/s41598-024-73627-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: 08/05/2024] [Accepted: 09/19/2024] [Indexed: 09/29/2024] Open
Abstract
To evaluate the efficacy and safety of four techniques of partial breast irradiation (PBI) including interstitial brachytherapy (ISBT), balloon-based brachytherapy (BBT), Intraoperative radiotherapy (IORT) and three-dimensional conformal radiotherapy (3DCRT) in the treatment for early-stage breast cancer patients after breast-conserving surgery. A systematic search was performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) guidelines using the PubMed, Embase, Cochrane Library and Web of Science databases. The inclusion criteria were clinical trials and observational studies that reported on outcome measures of principal PBI techniques. The methodological quality of the included research data was assessed using bias risk assessment tool with the Methodological Index for Non-Randomized Studies (MINORS), and the research information were analyzed using data analysis software. Clinical studies were collected from the earliest available date until September 2023. Fifty-one studies were included, with a total sample size of 7708. The results of network meta-analysis (NMA) showed that ISBT can lower the local recurrence (SUCRA: 73.8%). In terms of reducing distant metastasis, 3DCRT may be the best choice (SUCRA: 52.5%). And IORT has the highest 5-year overall survival (SUCRA: 90%). Furthermore, ISBT also has the advantages of lowest risk with fat necrosis (SUCRA: 72.5%), infection (SUCRA: 78.3%) and breast pain (SUCRA: 86.2%). BBT may be the optimal solution for fibrosis (SUCRA: 76.9%) and hyperpigmentation (SUCRA: 66.7%). 3DCRT has lower incidence of telangiectasia (SUCRA: 56.7%) and better cosmetic result (SUCRA: 85%). Postoperative PBI treatment using ISBT after breast-conserving surgery in patients with early-stage breast cancer may be a more valuable choice based on the treatment efficacy and is associated with fewer late side-effects. Large-scale, prospective, long-term studies are warranted to clarify the role of different PBI techniques in selected patients.
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Affiliation(s)
- Jing Ning
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, 130033, Changchun, Jilin, China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, 130033, Changchun, Jilin, China
| | - Ning Wu
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, No.126 Xiantai Street, 130033, Changchun, Jilin, China.
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Chang JS, Lee J, Vicini FA, Kim JS, Kim J, Choi SH, Lee IJ, Kim YB. Large institutional experience of early outcomes and dosimetric findings with postoperative stereotactic partial breast irradiation in breast cancer. Radiother Oncol 2024; 191:110066. [PMID: 38142936 DOI: 10.1016/j.radonc.2023.110066] [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: 09/13/2023] [Revised: 12/04/2023] [Accepted: 12/17/2023] [Indexed: 12/26/2023]
Abstract
PURPOSE To analyze the dosimetric and toxicity outcomes of patients treated with postoperative stereotactic partial breast irradiation (S-PBI). METHODS We identified 799 women who underwent S-PBI at our institution between January 2016 and December 2022. The most commonly used dose-fraction and technique were 30 Gy in 5 fractions (91.7 %) and a robotic stereotactic radiation system with real-time tracking (83.7 %). The primary endpoints were dosimetric parameters and radiation-related toxicities. For comparison, a control group undergoing ultra-hypofractionated whole breast irradiation (UF-WBI, n = 468) at the same institution was selected. RESULTS A total of 815 breasts from 799 patients, with a median planning target volume (PTV) volume of 89.6 cm3, were treated with S-PBI. Treatment plans showed that the mean and maximum doses received by the PTV were 96.2 % and 104.8 % of the prescription dose, respectively. The volume of the ipsilateral breast that received 50 % of the prescription dose was 32.3 ± 8.9 %. The mean doses for the ipsilateral lung and heart were 2.5 ± 0.9 Gy and 0.65 ± 0.39 Gy, respectively. Acute toxicity occurred in 175 patients (21.5 %), predominantly of grade 1. Overall rate of late toxicity was 4 % with a median follow-up of 31.6 months. Compared to the UF-WBI group, the S-PBI group had comparably low acute toxicity (21.5 % vs. 25.2 %, p = 0.12) but significantly lower dosimetric parameters for all organs-at-risks (all p < 0.05). CONCLUSION In this large cohort, S-PBI demonstrated favorable dosimetric and toxicity profiles. Considering the reduced radiation exposure to surrounding tissues, external beam PBI with advanced techniques should at least be considered over traditional WBI-based approaches for PBI candidates.
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Affiliation(s)
- Jee Suk Chang
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Jeongshim Lee
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea; Inha University Hospital, Inha University College of Medicine, Incheon, Republic of Korea
| | - Frank A Vicini
- Department of Radiation Oncology, Michigan Healthcare Professionals, Farmington Hills, MI, USA
| | - Jin Sung Kim
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jihun Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seo Hee Choi
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ik Jae Lee
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
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Merten R, Fischer M, Kopytsia G, Wichmann J, Lange T, Knöchelmann AC, Becker JN, Klapdor R, Hinrichs J, Bremer M. Linac-Based Ultrahypofractionated Partial Breast Irradiation (APBI) in Low-Risk Breast Cancer: First Results of a Monoinstitutional Observational Analysis. Cancers (Basel) 2023; 15:cancers15041138. [PMID: 36831481 PMCID: PMC9954287 DOI: 10.3390/cancers15041138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/15/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
Purpose: For adjuvant radiotherapy of low-risk breast cancer after breast-conserving surgery, there have been many trials of hypofractionation and partial breast irradiation (PBI) over the years, with proven mild long-term toxicity. The aim of this study was to introduce a short-course dose-adapted concept, proven in whole breast irradiation (WBI) for use in accelerated partial breast irradiation (APBI), while monitoring dosimetric data and toxicity. Methods: From April 2020 to March 2022, 61 patients with low-risk breast cancer or ductal carcinoma in situ (DCIS) were treated at a single institution with percutaneous APBI of 26 Gy in five fractions every other day after breast-conserving surgery. Dosimetric data for target volume and organs at risk were determined retrospectively. Acute toxicity was evaluated. Results: The target volume of radiotherapy comprised an average of 19% of the ipsilateral mamma. The burden on the heart and lungs was very low. The mean cardiac dose during irradiation of the left breast was only 0.6 Gy. Two out of three patients remained without any acute side effects. Conclusions: Linac-based APBI is an attractive treatment option for patients with low-risk breast cancer in whom neither WBI nor complete omission of radiotherapy appears to be an adequate alternative.
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Affiliation(s)
- Roland Merten
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
- Correspondence:
| | - Mirko Fischer
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Gennadii Kopytsia
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Jörn Wichmann
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Tim Lange
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | | | - Jan-Niklas Becker
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
| | - Rüdiger Klapdor
- Clinic for Gynecology and Obstetrics, Hannover Medical School, 30625 Hannover, Germany
| | - Jan Hinrichs
- Institute for Radiology, Hannover Medical School, 30625 Hannover, Germany
| | - Michael Bremer
- Clinic for Radiotherapy, Hannover Medical School, 30625 Hannover, Germany
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Chang JS, Khan AJ. Accelerated Partial Breast Irradiation: Technological Advances and Current Challenges. Am J Clin Oncol 2023; 46:7-9. [PMID: 36562690 DOI: 10.1097/coc.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Accelerated partial breast irradiation is a mature, standard-of-care treatment option for many women with early-stage breast cancer. In this paper, we discuss technological challenges and advances in the delivery of accurate and reproducible accelerated partial breast irradiation.
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Affiliation(s)
- Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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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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8
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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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9
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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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Joo JH, Ki Y, Jeon H, Kim DW, Jung J, Kim SS. Who are the optimal candidates for partial breast irradiation? Asia Pac J Clin Oncol 2020; 17:305-311. [PMID: 33078898 DOI: 10.1111/ajco.13462] [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: 10/23/2019] [Accepted: 09/05/2020] [Indexed: 11/28/2022]
Abstract
At the 2017 St. Gallen International Expert Consensus Conference on the Primary Therapy for Early Breast Cancer, the consensus panel recognized "partial breast irradiation as an option for women meeting the low-risk criteria put forward by the American Society for Radiation Oncology/European Society for Radiotherapy and Oncology (ASTRO/ESTRO) guideline," although acknowledging that there was less evidence for this approach. Partial breast irradiation is defined as irradiation localized to the surgical resection cavity only as opposed to the entire breast. Accelerated partial breast irradiation (APBI) involves intensive treatment in a short time period. The methods vary, and three available APBI options are brachytherapy, external beam and intra-operative irradiation. The long-term follow-up results from two large-scale, well-designed phase III randomized clinical trials have been released. However, further discussion of the optimal treatment candidates and delivery method is needed before the clinical application of APBI as a mainstream breast conservation treatment.
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Affiliation(s)
- Ji Hyeon Joo
- Department of Radiation Oncology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Yongkan Ki
- Department of Radiation Oncology, Pusan National University School of Medicine, Yangsan, South Korea
| | - Hosang Jeon
- Department of Radiation Oncology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Dong Woon Kim
- Department of Radiation Oncology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Jinhong Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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11
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Plasma antioxidant substances apparently do not influence the radiodermatitis occurrence. SCIENTIA MEDICA 2020. [DOI: 10.15448/1980-6108.2020.1.35844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIMS: Radiation affects not only tumors but also healthy tissues through the increment of oxidative stress. Thus, this study aimed to evaluate the oxidative stress degree as well as non-enzymatic antioxidant defenses in the plasma of patients submitted to radiotherapy and to verify if these parameters are modified in those patients who develop radiodermatitis.METHODS: Forty-one patients submitted to radiotherapy for treatment of breast cancer were followed. From these patients, plasma samples were obtained at the beginning, in the middle and at the end of the treatment, for analysis of thiobarbituric acid reactive substances (TBARS) and ferric reducing ability of plasma (FRAP).RESULTS: No significant differences were observed in terms of TBARS and FRAP in plasma harvested from these patients at the beginning and at the middle of the treatment. There was lower incidence of grade two radiodermatitis among patients undergoing radiotherapy with hypofractionated doses. There were no differences in FRAP or TBARS among patients who developed radiodermatitis of any degree in relation to those who did not develop this side effect. No differences of FRAP or TBARS were observed between patients that presented grade two radiodermatitis regarding to the others studied.CONCLUSION: There was no clear relationship between changes in TBARS or FRAP with the occurrence or severity of radiodermatitis.
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12
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Belkacemi Y, Debbi K, Loganadane G, Ghith S, Hadhri A, Hassani W, Cherif MA, Coraggio G, To NH, Colson-Durand L, Grellier N. [Adjuvant and neoadjuvant radiotherapy in breast cancer: A literaure review and update on the state of the evidence in 2020]. Cancer Radiother 2020; 24:482-492. [PMID: 32839105 DOI: 10.1016/j.canrad.2020.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 12/19/2022]
Abstract
Radiation therapy has benefited from many developments over the past 20 years. These developments are mainly linked to the technology, imaging and informatics evolutions which allow better targets definitions, ensure better organs-at-risk sparing and excellent reproducibility of treatments, with a perfect control of patient positioning. In breast cancer radiotherapy, the evolution was marked by the possibility of reducing the duration of treatments from 6-7 to 3-4 weeks by using hypofractionated regimens, or by further reducing the irradiation to one week when treatment is solely focalised to the tumour bed. This concept of accelerated partial breast irradiation has challenged the paradigm of the obligation to irradiate the whole breast after conservative surgery in all patients. In addition, the technical mastery of accelerated partial breast irradiation and the development of stereotactic radiotherapy techniques are currently contributing to the development of research projects in neoadjuvant settings. Thus, numerous ongoing studies are evaluating the impact of high-dose preoperative tumour irradiation, alone or in combination with systemic treatments, on biological tumor changes, on anti-tumour immunity, and on the pathologic complete response, which is considered as predictive of better long-term survival in some molecular breast cancer subtypes. In this review, we discuss all these developments which allow breast radiation therapy to enter the era of personalisation of treatments in oncology.
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Affiliation(s)
- Y Belkacemi
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Centre sein Henri-Mondor, hôpitaux universitaires Henri-Mondor, 94010 Créteil, France; Inserm U955 equipe 21, IMRB, 94010 Créteil, France.
| | - K Debbi
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - G Loganadane
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Inserm U955 equipe 21, IMRB, 94010 Créteil, France
| | - S Ghith
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Centre sein Henri-Mondor, hôpitaux universitaires Henri-Mondor, 94010 Créteil, France
| | - A Hadhri
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - W Hassani
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - M A Cherif
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - G Coraggio
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - N H To
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Inserm U955 equipe 21, IMRB, 94010 Créteil, France
| | - L Colson-Durand
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France
| | - N Grellier
- Service d'oncologie-radiothérapie-AP-HP, hôpitaux universitaires Henri-Mondor et université Paris Est Créteil, 94010 Créteil, France; Centre sein Henri-Mondor, hôpitaux universitaires Henri-Mondor, 94010 Créteil, France
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13
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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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14
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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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15
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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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16
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Wang K, Yee C, Tam S, Drost L, Chan S, Zaki P, Rico V, Ariello K, Dasios M, Lam H, DeAngelis C, Chow E. Prevalence of pain in patients with breast cancer post-treatment: A systematic review. Breast 2018; 42:113-127. [DOI: 10.1016/j.breast.2018.08.105] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/08/2018] [Accepted: 08/27/2018] [Indexed: 12/12/2022] Open
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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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18
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Corbin KS, Mutter RW. Proton therapy for breast cancer: progress & pitfalls. BREAST CANCER MANAGEMENT 2018. [DOI: 10.2217/bmt-2018-0001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
As the number of patients cured from breast cancer increases with improvements in multidisciplinary care, emphasis on reducing late toxicities of treatment has increased, in order to improve long-term quality of life. Proton beam therapy (PBT) is a form of radiotherapy that uses particles with unique physical properties that enable treatment delivery with minimal dose deposition beyond the treatment target. Therefore, PBT has emerged as an exciting radiotherapy modality for breast cancer due to the ability to minimize exposure to the heart, lungs, muscle, and bone. Herein, we review the rationale for PBT in breast cancer, potential clinical applications, and the available clinical data supporting its use. We also address some of the technical and logistical challenges and areas of ongoing research that will ultimately establish the role for PBT for breast cancer in the years ahead.
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Affiliation(s)
- Kimberly S Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
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19
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Seven-Year Outcomes Following Accelerated Partial Breast Irradiation Stratified by ASTRO Consensus Groupings. Am J Clin Oncol 2017; 40:483-489. [PMID: 25844825 DOI: 10.1097/coc.0000000000000190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Limited long-term data exist regarding outcomes for patients treated with accelerated partial breast irradiation (APBI), particularly, when stratified by American Society for Radiation Oncology (ASTRO) Consensus Statement (CS) risk groups. The purpose of this analysis is to present 5- and 7-year outcomes following APBI based on CS groupings. MATERIALS AND METHODS A total of 690 patients with early-stage breast cancer underwent APBI from 1993 to 2012, receiving interstitial brachytherapy (n=195), balloon-based brachytherapy (n=290), or 3-dimensional conformal radiotherapy (n=205) at a single institution. Patients were stratified into suitable, cautionary, and unsuitable groups with 5-year outcomes analyzed. Seven-year outcomes were analyzed for a subset with follow-up of ≥2 years (n=625). RESULTS Median follow-up was 6.7 years (range, 0.1 to 20.1 y). Patients assigned to cautionary and unsuitable categories were more likely to have high-grade tumors (21% to 25% vs. 9%, P=0.001), receive chemotherapy (15% to 38% vs. 6%, P<0.001), and have close/positive margins (9% to 11% vs. 0%, P<0.001). There was no difference in ipsilateral breast tumor recurrence at 5 or 7 years: 2.2%, 1.2%, 2.8% at 5 years (P=0.57), and 2.2%, 1.9%, 4.6% at 7 years (P=0.58) in the suitable, cautionary, and unsuitable groups, respectively. As compared with the suitable group, increased rates of distant metastases were noted for the unsuitable and cautionary groups at 5 years (P=0.04). CONCLUSIONS No differences in rates of ipsilateral breast tumor recurrence were seen at 5 or 7 years when stratified by ASTRO CS groupings. Modest increases in distant recurrence were noted in the cautionary and unsuitable groups. These findings suggest that the ASTRO CS groupings stratify more for systemic recurrence and may not appropriately select patients for whole versus partial breast irradiation.
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20
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Impact of adjuvant systemic chemotherapy on wound healing and cosmetic outcome in 224 women treated with accelerated partial breast irradiation using interstitial brachytherapy. Brachytherapy 2017; 16:935-942. [DOI: 10.1016/j.brachy.2017.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/02/2017] [Accepted: 06/07/2017] [Indexed: 11/22/2022]
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21
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Shah S, Kyrillos A, Kuchta K, Habib H, Tobias M, Raghavan V, Shaikh A, Bloomer W, Pesce C, Yao K. A Single Institution Retrospective Comparison Study of Locoregional Recurrence After Accelerated Partial Breast Irradiation Using External Beam Fractionation Compared with Whole Breast Irradiation with 8 Years of Follow-Up. Ann Surg Oncol 2017; 24:2935-2942. [PMID: 28766205 DOI: 10.1245/s10434-017-5953-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Accelerated partial breast irradiation (APBI) was developed to address disadvantages of overall treatment time and potentially unnecessary radiation associated with whole breast irradiation (WBI). We report updated results of our single institution study using an external beam APBI regimen with a median follow-up of 8 years. METHODS A total of 290 APBI patients with AJCC Stage 0-II breast cancer were compared with 290 WBI patients with matched tumor characteristics. Toxicities were scored based on the Common Terminology Criteria for Adverse Events (CTCAE v3.0). Cox regression models were used to predict likelihood of freedom from ipsilateral failure. RESULTS Median follow-up was 8 years in the APBI group and 7.5 years in the WBI group. In the APBI group, there were 18 (6.2%) ipsilateral breast tumor recurrence (IBTR), 13 (72%) had elsewhere failures (EF), and 5 (28%) had local failures (LF) with a median time to failure of 64.1 months. In the WBI group, there were three (1.0%) IBTR; one (33%) was an EF and two (67%) were LF with a median time to failure of 91 months. APBI was 4.6 times more likely (hazard ratio 4.57, 95% confidence interval 1.3-16.2, p = 0.02) to have an IBTR than WBI after adjusting for age, tumor size, histology, grade, and estrogen receptor status. Fatigue, erythema, and desquamation toxicities were significantly less in the APBI group then the WBI group. CONCLUSIONS IBTR rates were higher in external beam APBI group compared with WBI, but APBI had fewer toxicities. Clinicians must weigh the risks and benefits of APBI when making a recommendation for partial breast irradiation after lumpectomy.
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Affiliation(s)
- Shalin Shah
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Alexandra Kyrillos
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Kristine Kuchta
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Hussain Habib
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Megan Tobias
- Department of Radiation Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Vathsala Raghavan
- Department of Radiation Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Arif Shaikh
- Department of Radiation Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - William Bloomer
- Department of Radiation Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Catherine Pesce
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Katharine Yao
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
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22
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Cuaron JJ, MacDonald SM, Cahlon O. Novel applications of proton therapy in breast carcinoma. Chin Clin Oncol 2017; 5:52. [PMID: 27558253 DOI: 10.21037/cco.2016.06.04] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/28/2016] [Indexed: 12/18/2022]
Abstract
This review will focus on the indications, clinical experience, and technical considerations of proton beam radiation therapy in the treatment of patients with breast cancer. For patients with early stage disease, proton therapy delivers less dose to non-target breast tissue for patients receiving partial breast irradiation (PBI) therapy, which may result in improved cosmesis but requires further investigation. For patients with locally advanced breast cancer requiring treatment to the regional lymph nodes, proton therapy allows for an improved dosimetric profile compared with conventional photon and electron techniques. Early clinical results demonstrate acceptable toxicity. The possible reduction in cardiopulmonary events as a result of reduced dose to organs at risk will be tested in a randomized control trial of protons vs. photons.
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Affiliation(s)
- John J Cuaron
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Shannon M MacDonald
- Massachusetts General Hospital, Francis H. Burr Proton Therapy Center, Boston, MA 02114-7250, USA
| | - Oren Cahlon
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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23
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Wang EH, Park HS, Rutter CE, Gross CP, Soulos PR, Yu JB, Evans SB. Association between access to accelerated partial breast irradiation and use of adjuvant radiotherapy. Cancer 2017; 123:502-511. [PMID: 27657353 DOI: 10.1002/cncr.30356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/16/2016] [Accepted: 09/01/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND The current study was performed to determine whether access to facilities performing accelerated partial breast irradiation (APBI) is associated with differences in the use of adjuvant radiotherapy (RT). METHODS Using the National Cancer Data Base, the authors performed a retrospective study of women aged ≥50 years who were diagnosed with early-stage breast cancer between 2004 and 2013 and treated with breast-conserving surgery (BCS). Facilities performing APBI in ≥10% of their eligible patients within a given year were defined as APBI facilities whereas those not performing APBI were defined as non-APBI facilities. All other facilities were excluded. The authors identified independent factors associated with RT use using multivariable logistic regression with clustering in the overall sample as well as in subsets of patients with standard-risk invasive cancer, low-risk invasive cancer, and ductal carcinoma in situ. RESULTS Among 222,544 patients, 76.6% underwent BCS plus RT and 23.4% underwent BCS alone. The likelihood of RT receipt in the overall sample did not appear to differ significantly between APBI and non-APBI facilities (adjusted odds ratio [AOR], 1.02; P = .61). Subgroup multivariable analysis demonstrated that among patients with standard-risk invasive cancer, there was no association between evaluation at an APBI facility and receipt of RT (AOR, 0.98; P = .69). However, patients with low-risk invasive cancer were found to be significantly more likely to receive RT (54.4% vs 59.5%; AOR, 1.22 [P<.001]), whereas patients with ductal carcinoma in situ were less likely to receive RT (56.9% vs 55.3%; AOR, 0.89 [P = .04]) at APBI facilities. CONCLUSIONS Patients who were eligible for observation were more likely to receive RT in APBI facilities but no difference was observed among patients with standard-risk invasive cancer who would most benefit from RT. Cancer 2017;123:502-511. © 2016 American Cancer Society.
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Affiliation(s)
- Elyn H Wang
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Henry S Park
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Charles E Rutter
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Cary P Gross
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Pamela R Soulos
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut
| | - James B Yu
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Suzanne B Evans
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
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24
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Sanford NN, Taghian AG. Accelerated Partial Breast Irradiation. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Nichols E, Kesmodel SB, Bellavance E, Drogula C, Tkaczuk K, Cohen RJ, Citron W, Morgan M, Staats P, Feigenberg S, Regine WF. Preoperative Accelerated Partial Breast Irradiation for Early-Stage Breast Cancer: Preliminary Results of a Prospective, Phase 2 Trial. Int J Radiat Oncol Biol Phys 2016; 97:747-753. [PMID: 28244410 DOI: 10.1016/j.ijrobp.2016.11.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 11/07/2016] [Accepted: 11/19/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To assess the feasibility of utilizing 3-dimensional conformal accelerated partial-breast irradiation (APBI) in the preoperative setting followed by standard breast-conserving therapy. PATIENTS AND METHODS This was a prospective trial testing the feasibility of preoperative APBI followed by lumpectomy for patients with early-stage invasive ductal breast cancer. Eligible patients had T1-T2 (<3 cm), N0 tumors. Patients received 38.5 Gy in 3.85-Gy fractions delivered twice daily. Surgery was performed >21 days after radiation therapy. Adjuvant therapy was given as per standard of care. RESULTS Twenty-seven patients completed treatment. With a median follow-up of 3.6 years (range, 0.5-5 years), there have been no local or regional failures. A complete pathologic response according to hematoxylin and eosin stains was seen in 4 patients (15%). There were 4 grade 3 seromas. Patient-reported cosmetic outcome was rated as good to excellent in 79% of patients after treatment. CONCLUSIONS Preoperative 3-dimensional conformal radiation therapy-APBI is feasible and well tolerated in select patients with early-stage breast cancer, with no reported local recurrences and good to excellent cosmetic results. The pathologic response rates associated with this nonablative APBI dose regimen are particularly encouraging and support further exploration of this paradigm.
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Affiliation(s)
- Elizabeth Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland.
| | - Susan B Kesmodel
- Department of Surgical Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Emily Bellavance
- Department of Surgical Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cynthia Drogula
- Department of Surgical Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katherine Tkaczuk
- Department of Medical Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Randi J Cohen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Wendla Citron
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michelle Morgan
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Paul Staats
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Steven Feigenberg
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - William F Regine
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
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26
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Mészáros N, Major T, Stelczer G, Zaka Z, Mózsa E, Pukancsik D, Takácsi-Nagy Z, Fodor J, Polgár C. Implementation of image-guided intensity-modulated accelerated partial breast irradiation : Three-year results of a phase II clinical study. Strahlenther Onkol 2016; 193:70-79. [PMID: 27872946 DOI: 10.1007/s00066-016-1074-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/19/2016] [Indexed: 01/19/2023]
Abstract
PURPOSE To report 3‑year results of accelerated partial breast irradiation (APBI) using image-guided intensity-modulated radiotherapy (IG-IMRT) following breast conserving surgery (BCS) for low-risk early invasive breast cancer. PATIENTS AND METHODS Between July 2011 and March 2014, 60 patients with low-risk early invasive breast cancer underwent BCS and were enrolled in this phase II prospective study. The total dose was 36.9 Gy (9 fractions of 4.1 Gy, two fractions/day). Patient setup errors were detected in LAT, LONG and VERT directions. Local tumour control, survival results, early and late side effects and cosmetic outcome were assessed. RESULTS At a median follow-up of 39 months, all patients were alive and neither locoregional nor distant failure occurred. One contralateral breast cancer and two new primary malignancies outside the breast were observed. No grade (G) 3-4 acute toxicity was detected. G1 and G2 erythema occurred in 21 (35%) and 2 (3.3%) patients, respectively; while G1 oedema was observed in 23 (38.8%) cases. G1 and G2 pain was reported by 6 (10%) and 2 (3.3%) patients, respectively. Among the late radiation side effects, G1 pigmentation or telangiectasia, G1 fibrosis and G1 asymptomatic fat necrosis occurred in 10 (16.7%), 7 (11.7%) and 3 (5%) patients, respectively. No ≥ G2 late toxicity was detected. Cosmetic outcome was excellent in 43 (71.7%) and good in 17 (28.3%) patients. CONCLUSION IG-IMRT is a reproducible and feasible technique for delivery of external beam APBI following BCS for treatment of low-risk, early-stage invasive breast carcinoma. In order to avoid toxicity, image guidance performed before each radiation fraction is necessary to minimize the PTV. Three-year results are promising, early and late radiation side-effects are minimal, and cosmetic results are excellent to good.
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Affiliation(s)
- Norbert Mészáros
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
| | - Gábor Stelczer
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
| | - Zoltán Zaka
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
| | - Emőke Mózsa
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary.,Department of Radiooncology and Radiotherapy, Landesklinikum, Wiener Neustadt, Austria
| | - 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, 1122, Budapest, Hungary
| | - János Fodor
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Ráth György u. 7-9, 1122, Budapest, Hungary
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27
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Brachytherapy-based Accelerated Partial Breast Irradiation Provides Equivalent 10-Year Outcomes to Whole Breast Irradiation. Am J Clin Oncol 2016; 39:468-72. [DOI: 10.1097/coc.0000000000000082] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Correa C, Harris EE, Leonardi MC, Smith BD, Taghian AG, Thompson AM, White J, Harris JR. Accelerated Partial Breast Irradiation: Executive summary for the update of an ASTRO Evidence-Based Consensus Statement. Pract Radiat Oncol 2016; 7:73-79. [PMID: 27866865 DOI: 10.1016/j.prro.2016.09.007] [Citation(s) in RCA: 447] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 09/12/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To update the accelerated partial breast irradiation Consensus Statement published in 2009 and provide guidance on use of intraoperative radiation therapy (IORT) for partial breast irradiation in early-stage breast cancer, based on published evidence complemented by expert opinion. METHODS AND MATERIALS A systematic PubMed search using the same terms as the original Consensus Statement yielded 419 articles; 44 articles were selected. The authors synthesized the published evidence and, through a series of conference calls and e-mails, reached consensus regarding the recommendations. RESULTS The new recommendations include lowering the age in the "suitability group" from 60 to 50 years and in the "cautionary group" to 40 years for patients who meet all other elements of suitability (Table 1). Patients with low-risk ductal carcinoma in situ, as per Radiation Therapy Oncology Group 9804 criteria, were categorized in the "suitable" group. The task force agreed to maintain the current criteria based on margin status. Recommendations for the use of IORT for breast cancer patients include: counseling patients regarding the higher risk of ipsilateral breast tumor recurrence with IORT compared with whole breast irradiation; the need for prospective monitoring of long-term local control and toxicity with low-energy radiograph IORT given limited follow-up; and restriction of IORT to women with invasive cancer considered "suitable." CONCLUSION These recommendations will provide updated clinical guidance regarding use of accelerated partial breast irradiation for radiation oncologists and other specialists participating in the care of breast cancer patients.
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Affiliation(s)
- Candace Correa
- Department of Radiation Oncology, Faxton St. Luke's Healthcare, Utica, New York
| | - Eleanor E Harris
- Department of Radiation Oncology, East Carolina University, Greenville, North Carolina
| | | | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alastair M Thompson
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Julia White
- Department of Radiation Oncology, Ohio State University Cancer Center, Columbus, Ohio
| | - Jay R Harris
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
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29
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Poortmans PMP, Arenas M, Livi L. Over-irradiation. Breast 2016; 31:295-302. [PMID: 27522160 DOI: 10.1016/j.breast.2016.07.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/16/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022] Open
Abstract
Decreasing the burden of radiation therapy (RT) for breast cancer includes, next to complete omission, several ways to tailor the extent of RT. Possible options for this include lowering of the total dose, such as selective omission of the boost, hypofractionated RT to shorten the duration of treatment, the selective introduction of partial breast irradiation and anatomy based target volume contouring to decrease the size of the irradiated volumes. Elective regional nodal irradiation showed in several randomised trials and meta-analyses to significantly impact on local-regional control, disease-free survival, breast cancer mortality and overall survival. The generalisability of these results remains complex in the light of the decreasing use of axillary lymph node dissection, the use of more effective adjuvant systemic therapy, the increasing use of primary systemic therapy and continuously improving RT techniques. In general, the use of RT compensates for the decreasing extent of surgery to the breast and the axillary lymph nodes, eliminating residual tumour cells while maintaining better aesthetic and functional results. In some occasions, however, the indications for the extent of RT have to be based on limited pathological staging information. Research is ongoing to individualise RT more on the basis of biological factors including gene expression profiles. When considering age, treatment decisions should rather be based on biological instead of formal age. The aim of this review article is to put current evidence into the right perspective, and to search for an appropriate appreciation of the balance between efficacy and side effects of local-regional RT.
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Affiliation(s)
- Philip M P Poortmans
- Department of Radiation Oncology, Radboud university medical center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
| | - Meritxell Arenas
- Department of Radiation Oncology, University Hospital Sant Joan de Reus, Av. del Dr. Josep Laporte, 2, 43204 Reus, Spain.
| | - Lorenzo Livi
- Radiation Oncology Unit, Florence University Hospital, Largo G. A. Brambilla, 3, 50134 Florence, Italy.
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30
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Five-year results of a prospective clinical trial investigating accelerated partial breast irradiation using 3D conformal radiotherapy after lumpectomy for early stage breast cancer. Breast 2016; 28:178-83. [DOI: 10.1016/j.breast.2016.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 04/09/2016] [Accepted: 06/01/2016] [Indexed: 01/19/2023] Open
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Akhtari M, Teh BS. Accelerated partial breast irradiation: advances and controversies. CHINESE JOURNAL OF CANCER 2016; 35:31. [PMID: 27013323 PMCID: PMC4807571 DOI: 10.1186/s40880-016-0095-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/02/2016] [Indexed: 12/26/2022]
Abstract
The management of localized breast cancer has changed dramatically over the past three to four decades. Breast-conserving therapy, which involved lumpectomy followed by adjuvant irradiation, is now widely considered the standard of care in women with early-stage breast cancer. Accelerated partial breast irradiation (APBI), which involves focal irradiation of the lumpectomy cavity over a short period of time, has developed over the past two decades as an alternative to whole breast irradiation (WBI). Multiple APBI modalities have been developed including brachytherapy, external beam irradiation, and intraoperative irradiation. These new techniques have provided early-stage breast cancer patients with shorter treatment duration and more focused irradiation, delivering very high biological doses to the region at a high risk of failures over a much shorter treatment course as compared with conventional radiotherapy. However, the advantages of APBI over conventional radiotherapy are controversial, including a higher risk of complications reported in retrospective literature and shorter follow-up duration in the intraoperative APBI trials. Nevertheless, APBI presents a valuable alternative to WBI for a selected population of women with early-stage breast cancer.
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Affiliation(s)
- Mani Akhtari
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Weil Cornell Medical College, 6565 Fannin, Ste#DB1-077, Houston, TX, 77030, USA.,Department of Radiation Oncology, The University of Texas Medical Branch at Galveston, Houston, TX, 77555, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Weil Cornell Medical College, 6565 Fannin, Ste#DB1-077, Houston, TX, 77030, USA.
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32
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Khan AJ, Ahlawat S, Goyal S. Novel and Highly Compressed Schedules for the Treatment of Breast Cancer. Semin Radiat Oncol 2015; 26:45-50. [PMID: 26617209 DOI: 10.1016/j.semradonc.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Our thinking about radiotherapy (RT) for early-stage breast cancer has evolved considerably over the last several years. Increasingly patients and physicians together are making the decision to use altered fractionation rather than standard 6-7 weeks of conventional whole breast treatment plus lumpectomy bed boost. Adjuvant hypofractionated whole breast irradiation is now viewed as a preferred strategy for many eligible women, and can be completed in 3-4 weeks. Adjuvant accelerated partial breast irradiation is another alternative that is typically delivered in 8-10 fractions over 4-5 days. With improvements in delivery techniques, there has been renewed interest in shortening treatment times even further, with novel intraoperative approaches and ultrashort courses of external beam RT. This article provides a summary of the status and future directions in intraoperative and ultrashort course RT schedules used in the treatment of breast cancer. Outlined are the benefits as well as the drawbacks of these techniques for abbreviated breast RT.
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Affiliation(s)
- Atif J Khan
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
| | - Stuti Ahlawat
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Sharad Goyal
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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33
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Avanzo M, Trovo M, Stancanello J, Jena R, Roncadin M, Toffoli G, Zuiani C, Capra E. Hypofractionation of partial breast irradiation using radiobiological models. Phys Med 2015; 31:1022-1028. [PMID: 26508014 DOI: 10.1016/j.ejmp.2015.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/10/2015] [Accepted: 08/03/2015] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To reduce the fraction number in Partial Breast Irradiation (PBI) with initial prescription of 40 Gy in 10 fractions using radiobiological models with specific focus on risk of moderate/severe radiation-induced fibrosis (RIF) and report clinical results. METHODS AND MATERIALS 68 patients (patient group A) were treated with 40 Gy in 10 fractions delivered by field-in-field, forward-planned IMRT. Isotoxic regimens with decreasing number of fractions were calculated using Biological Effective Dose (BED) to the breast. Risk for RIF in hypofractionated treatment was predicted by calculating NTCP from DVHs of group A rescaled to fractions and dose of novel regimens. Moderate/severe RIF was prospectively scored during follow-up. Various NTCP models, with and without incomplete repair correction, were assessed from difference to observed incidence of RIF. In order to verify the value for α/β of 3 Gy assumed for breast, we fitted α/β to observed incidences of moderate/severe RIF. RESULTS Treatments with 35 Gy/7f and 28 Gy/4f were selected for the fraction reduction protocol. 75 patients (group B) were treated in 35 Gy/7f. Incidence of moderate/severe RIF was 5.9% in group A, 5.3% in group B. The NTCP model with correction for incomplete repair had lowest difference from observed RIF. The α/β obtained from fitting was 2.8 (95%CIs 1.1-10.7) Gy. CONCLUSIONS The hypofractionated regimen was well tolerated. The model for NTCP corrected for incomplete repair was the most accurate and an assumed α/β value of 3 Gy is consistent with our patient data. The hypofractionation protocol is continuing with patients treated with 28 Gy/4f.
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Affiliation(s)
- Michele Avanzo
- Medical Physics Department, CRO Aviano, 33081 Aviano, Italy.
| | - Marco Trovo
- Radiation Oncology Department, CRO Aviano, 33081 Aviano, Italy
| | | | - Rajesh Jena
- Department of Oncology, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Mario Roncadin
- Radiation Oncology Department, CRO Aviano, 33081 Aviano, Italy
| | - Giulia Toffoli
- Institute of Diagnostic Radiology, Department of Medical and Biological Sciences, University of Udine, 33100 Udine, Italy
| | - Chiara Zuiani
- Institute of Diagnostic Radiology, Department of Medical and Biological Sciences, University of Udine, 33100 Udine, Italy
| | - Elvira Capra
- Medical Physics Department, CRO Aviano, 33081 Aviano, Italy
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Riou O, Fenoglietto P, Bourgier C, Lauche O, Boulbair F, Charissoux M, Ducteil A, Aillères N, Lemanski C, Azria D. Feasibility of accelerated partial breast irradiation with volumetric-modulated arc therapy in elderly and frail patients. Radiat Oncol 2015; 10:209. [PMID: 26466672 PMCID: PMC4606890 DOI: 10.1186/s13014-015-0516-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 10/06/2015] [Indexed: 01/27/2023] Open
Abstract
Background Accelerated partial breast irradiation (APBI) is an option for adjuvant radiotherapy according to ASTRO and ESTRO recommendations. Among the available techniques, volumetric-modulated arc therapy (VMAT) is attractive but has not been extensively studied for APBI. This study assessed its feasibility, tolerance and early oncological outcomes. Methods We analysed the data of nine patients (median age 74 years) with ten lesions (one bilateral cancer) treated from May 2011 to July 2012 with APBI using VMAT. The radiation oncologist delineated the surgical tumour bed, and added an 18 mm isotropic margin to obtain the planning target volume (PTV). The dose was 40 Gy prescribed in 4 Gy fractions given twice a day over five days. Patients were regularly followed for toxicities and oncological outcomes. Results Mean PTV was 100.0 cm3 and 95 % of the PTV received a mean dose of 99.7 % of the prescribed dose. Hot spots represented 0.3 % of the PTV. 6.2 %, 1.6 % and 0.3 % of the ipsilateral lung volume received 5 Gy (V5Gy), 10 Gy (V10Gy) and 20 Gy (V20Gy), respectively. Regarding the contralateral lung, V5Gy was 0.3 %, and V10Gy and V20Gy were nil. V5Gy accounted for 3.1 % of the heart. An average 580 monitor units were delivered. No acute or late grade ≥ 2 toxicities were observed. With a median follow-up of 26 months, no relapses occurred. Conclusion In our study, VMAT allowed optimal dosimetry with consequential high therapeutic ratio in elderly and frail patients.
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Affiliation(s)
- Olivier Riou
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Pascal Fenoglietto
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Céline Bourgier
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Olivier Lauche
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Fatiha Boulbair
- Radiotherapy Department, Mulhouse Hospital, Mulhouse, France.
| | - Marie Charissoux
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Angélique Ducteil
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Norbert Aillères
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - Claire Lemanski
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
| | - David Azria
- Radiation Oncology Department, Institut régional du Cancer de Montpellier (ICM), Val d'Aurelle, 208 avenue des Apothicaires, 34298, Montpellier, cedex 5, France.
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35
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Cancer treatment-related neuropathic pain syndromes--epidemiology and treatment: an update. Curr Pain Headache Rep 2015; 18:459. [PMID: 25239766 DOI: 10.1007/s11916-014-0459-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cancer treatment-related chronic neuropathic pain (NP) is a pervasive and distressing problem that negatively influences function and quality of life for countless cancer survivors. It occurs because of cancer treatment-induced damage to peripheral and central nervous system structures. NP becomes chronic when pain signal transmission persists, eventually sensitizing neurons in the dorsal horn and other pain-processing regions in the central nervous system. Frequently overlooked, NP due to cancer treatment has been understudied. Consequently, only a few pharmacologic interventions have been shown to be effective based on the results of randomized controlled trials. Future research designed to explore pathophysiologic mechanisms and effective mechanism-targeted interventions is sorely needed.
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Peterson D, Truong PT, Parpia S, Olivotto IA, Berrang T, Kim DH, Kong I, Germain I, Nichol A, Akra M, Roy I, Reed M, Fyles A, Trotter T, Perera F, Balkwill S, Lavertu S, Elliott E, Julian JA, Levine MN, Whelan TJ. Predictors of Adverse Cosmetic Outcome in the RAPID Trial: An Exploratory Analysis. Int J Radiat Oncol Biol Phys 2015; 91:968-76. [DOI: 10.1016/j.ijrobp.2014.12.040] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 11/12/2014] [Accepted: 12/17/2014] [Indexed: 01/17/2023]
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van der Leij F, Bosma SCJ, van de Vijver MJ, Wesseling J, Vreeswijk S, Rivera S, Bourgier C, Garbay JR, Foukakis T, Lekberg T, van den Bongard DHJGD, van Vliet-Vroegindeweij C, Bartelink H, Rutgers EJ, Elkhuizen PHM. First results of the preoperative accelerated partial breast irradiation (PAPBI) trial. Radiother Oncol 2015; 114:322-7. [PMID: 25701298 DOI: 10.1016/j.radonc.2015.02.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 01/26/2015] [Accepted: 02/03/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study is to assess the toxicity and cosmetic outcome of preoperative accelerated partial breast irradiation (PAPBI) for breast cancer patients with low risk on local recurrence. MATERIAL AND METHODS Women aged ⩾60years with an invasive, unifocal ⩽3cm on MRI, (non-lobular) adenocarcinoma of the breast and a negative sentinel node received PAPBI (40Gray in 10 fractions over 2 weeks). Six weeks after radiotherapy a wide local excision was performed. RESULTS 70 patients with a median follow-up of 23 months (3-44 months) were evaluated. The overall postoperative infection rate was 11%. At 1, 2 and 3 years of follow-up respectively 89%, 98% and 100% of patients had no or mild induration-fibrosis. Fibrosis was only found in a small volume of the breast. The global cosmetic outcome was good to excellent in 77% at 6 months to 100% at 3 years. Two patients developed a local recurrence. CONCLUSION Our first results show limited fibrosis in a small volume and good to excellent cosmetic outcome. In selected patients, preoperative radiotherapy appears to be a good option for breast conserving therapy.
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Affiliation(s)
- Femke van der Leij
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Sophie C J Bosma
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Jelle Wesseling
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Sandra Vreeswijk
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | | | | | - Theodoros Foukakis
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Lekberg
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Harry Bartelink
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Emiel J Rutgers
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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Palta M, Palta P, Bhavsar NA, Horton JK, Blitzblau RC. The use of adjuvant radiotherapy in elderly patients with early-stage breast cancer: changes in practice patterns after publication of Cancer and Leukemia Group B 9343. Cancer 2014; 121:188-93. [PMID: 25488523 DOI: 10.1002/cncr.28937] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 06/02/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND The Cancer and Leukemia Group B (CALGB) 9343 randomized phase 3 trial established lumpectomy and adjuvant therapy with tamoxifen alone, rather than both radiotherapy and tamoxifen, as a reasonable treatment course for women aged >70 years with clinical stage I (AJCC 7th edition), estrogen receptor-positive breast cancer. An analysis of the Surveillance, Epidemiology, and End Results (SEER) registry was undertaken to assess practice patterns before and after the publication of this landmark study. METHODS The SEER database from 2000 to 2009 was used to identify 40,583 women aged ≥70 years who were treated with breast-conserving surgery for clinical stage I, estrogen receptor-positive and/or progesterone receptor-positive breast cancer. The percentage of patients receiving radiotherapy and the type of radiotherapy delivered was assessed over time. Administration of radiotherapy was further assessed across age groups; SEER cohort; and tumor size, grade, and laterality. RESULTS Approximately 68.6% of patients treated between 2000 and 2004 compared with 61.7% of patients who were treated between 2005 and 2009 received some form of adjuvant radiotherapy (P < .001). Coinciding with a decline in the use of external beam radiotherapy, there was an increase in the use of implant radiotherapy from 1.4% between 2000 and 2004 to 6.2% between 2005 to 2009 (P < .001). There were significant reductions in the frequency of radiotherapy delivery over time across age groups, tumor size, and tumor grade and regardless of laterality (P < .001 for all). CONCLUSIONS Randomized phase 3 data support the omission of adjuvant radiotherapy in elderly women with early-stage breast cancer. Analysis of practice patterns before and after the publication of these data indicates a significant decline in radiotherapy use; however, nearly two-thirds of women continue to receive adjuvant radiotherapy.
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Affiliation(s)
- Manisha Palta
- Department of Radiation Oncology, Duke University, Durham, North Carolina
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Breast-Conservative Surgery Followed by Radiofrequency Ablation of Margins Decreases the Need for a Second Surgical Procedure for Close or Positive Margins. Clin Breast Cancer 2014; 14:346-51. [DOI: 10.1016/j.clbc.2014.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 02/07/2014] [Accepted: 02/12/2014] [Indexed: 01/27/2023]
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40
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Lee CD. Recent developments and best practice in brachytherapy treatment planning. Br J Radiol 2014; 87:20140146. [PMID: 24734939 PMCID: PMC4453147 DOI: 10.1259/bjr.20140146] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/10/2014] [Accepted: 04/14/2014] [Indexed: 12/20/2022] Open
Abstract
Brachytherapy has evolved over many decades, but more recently, there have been significant changes in the way that brachytherapy is used for different treatment sites. This has been due to the development of new, technologically advanced computer planning systems and treatment delivery techniques. Modern, three-dimensional (3D) imaging modalities have been incorporated into treatment planning methods, allowing full 3D dose distributions to be computed. Treatment techniques involving online planning have emerged, allowing dose distributions to be calculated and updated in real time based on the actual clinical situation. In the case of early stage breast cancer treatment, for example, electronic brachytherapy treatment techniques are being used in which the radiation dose is delivered during the same procedure as the surgery. There have also been significant advances in treatment applicator design, which allow the use of modern 3D imaging techniques for planning, and manufacturers have begun to implement new dose calculation algorithms that will correct for applicator shielding and tissue inhomogeneities. This article aims to review the recent developments and best practice in brachytherapy techniques and treatments. It will look at how imaging developments have been incorporated into current brachytherapy treatment and how these developments have played an integral role in the modern brachytherapy era. The planning requirements for different treatments sites are reviewed as well as the future developments of brachytherapy in radiobiology and treatment planning dose calculation.
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Affiliation(s)
- C D Lee
- Physics Department, Clatterbridge Cancer Centre, Bebington, Wirral, UK
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41
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Hepel JT, Hiatt JR, Sha S, Leonard KL, Graves TA, Wiggins DL, Mastras D, Pittier A, Wazer DE. The rationale, technique, and feasibility of partial breast irradiation using noninvasive image-guided breast brachytherapy. Brachytherapy 2014; 13:493-501. [DOI: 10.1016/j.brachy.2014.05.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/08/2014] [Accepted: 05/12/2014] [Indexed: 01/28/2023]
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Ozyigit G, Gultekin M. Current role of modern radiotherapy techniques in the management of breast cancer. World J Clin Oncol 2014; 5:425-439. [PMID: 25114857 PMCID: PMC4127613 DOI: 10.5306/wjco.v5.i3.425] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/07/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Breast cancer is the most common type of malignancy in females. Advances in systemic therapies and radiotherapy (RT) provided long survival rates in breast cancer patients. RT has a major role in the management of breast cancer. During the past 15 years several developments took place in the field of imaging and irradiation techniques, intensity modulated RT, hypofractionation and partial-breast irradiation. Currently, improvements in the RT technology allow us a subsequent decrease in the treatment-related complications such as fibrosis and long-term cardiac toxicity while improving the loco-regional control rates and cosmetic results. Thus, it is crucial that modern radiotherapy techniques should be carried out with maximum care and efficiency. Several randomized trials provided evidence for the feasibility of modern radiotherapy techniques in the management of breast cancer. However, the role of modern radiotherapy techniques in the management of breast cancer will continue to be defined by the mature results of randomized trials. Current review will provide an up-to-date evidence based data on the role of modern radiotherapy techniques in the management of breast cancer.
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Quirk S, Conroy L, Smith WL. Accounting for respiratory motion in partial breast intensity modulated radiotherapy during treatment planning: a new patient selection metric. Eur J Cancer 2014; 50:1872-9. [PMID: 24835033 DOI: 10.1016/j.ejca.2014.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/28/2014] [Accepted: 04/12/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE External beam partial breast irradiation intensity modulated radiotherapy (PBI IMRT) plans experience degradation in coverage and dose homogeneity when delivered during respiration. We examine which characteristics of the breast and seroma result in unacceptable plan degradation due to respiration. METHODS Thirty-six patient datasets were planned with inverse-optimised PBI IMRT. Population respiratory data were used to create a probability density function. This probability density function (PDF) was convolved with the static plan fluences to calculate the delivered dose with respiration. To quantify the difference between static and respiratory plan quality, we analysed the mean dose shift of the target dose volume histogram (DVH), the dose shift at 95% of the volume and the dose shift at the hotspot to 2 cm(3)of the volume. We explore which patient characteristics indicate a clinically significant degradation in delivered plan quality due to respiration. RESULTS Dose homogeneity constraints, rather than dosimetric coverage, were the limiting factors for all patient plans. We propose the dose evaluation volume-to-planning target volume (DEV-to-PTV) ratio as a delineating metric for identifying patient plans that will be more degraded by respiratory motion. The DEV-to-PTV ratio may be a more robust metric than ipsilateral breast volume because the seroma volume is contoured more consistently between physicians and clinics. CONCLUSIONS For patients with a DEV-to-PTV ratio less than 55% we recommend either not using PBI IMRT or employing motion management. Small DEV-to-PTV ratios occur when the seroma is close to inhomogeneities (i.e. air/lung), which exacerbates the dosimetric effect of respiratory motion. For small breast sizes it is unlikely that the DEV-to-PTV ratio will meet these criteria.
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Affiliation(s)
- Sarah Quirk
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.
| | - Leigh Conroy
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Wendy L Smith
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
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Mellon EA, Sreeraman R, Gebhardt BJ, Mierzejewski A, Correa CR. Impact of radiation treatment parameters and adjuvant systemic therapy on cosmetic outcomes after accelerated partial breast irradiation using 3-dimensional conformal radiation therapy technique. Pract Radiat Oncol 2014; 4:e159-e166. [DOI: 10.1016/j.prro.2013.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 08/02/2013] [Accepted: 08/05/2013] [Indexed: 01/23/2023]
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Vera R, Trombetta M, Mukhopadhyay ND, Packard M, Arthur D. Long-term cosmesis and toxicity following 3-dimensional conformal radiation therapy in the delivery of accelerated partial breast irradiation. Pract Radiat Oncol 2014; 4:147-152. [DOI: 10.1016/j.prro.2013.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 06/17/2013] [Accepted: 07/04/2013] [Indexed: 11/26/2022]
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Cost-Effectiveness of 3-Dimensional Conformal Radiotherapy and Applicator-based Brachytherapy in the Delivery of Accelerated Partial Breast Irradiation. Am J Clin Oncol 2014; 37:172-6. [DOI: 10.1097/coc.0b013e318271b16d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liss AL, Ben-David MA, Jagsi R, Hayman JA, Griffith KA, Moran JM, Marsh RB, Pierce LJ. Decline of cosmetic outcomes following accelerated partial breast irradiation using intensity modulated radiation therapy: results of a single-institution prospective clinical trial. Int J Radiat Oncol Biol Phys 2014; 89:96-102. [PMID: 24613813 DOI: 10.1016/j.ijrobp.2014.01.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 01/04/2014] [Indexed: 12/22/2022]
Abstract
PURPOSE To report the final cosmetic results from a single-arm prospective clinical trial evaluating accelerated partial breast irradiation (APBI) using intensity modulated radiation therapy (IMRT) with active-breathing control (ABC). METHODS AND MATERIALS Women older than 40 with breast cancer stages 0-I who received breast-conserving surgery were enrolled in an institutional review board-approved prospective study evaluating APBI using IMRT administered with deep inspiration breath-hold. Patients received 38.5 Gy in 3.85-Gy fractions given twice daily over 5 consecutive days. The planning target volume was defined as the lumpectomy cavity with a 1.5-cm margin. Cosmesis was scored on a 4-category scale by the treating physician. Toxicity was scored according to National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 3.0). We report the cosmetic and toxicity results at a median follow-up of 5 years. RESULTS A total of 34 patients were enrolled. Two patients were excluded because of fair baseline cosmesis. The trial was terminated early because fair/poor cosmesis developed in 7 of 32 women at a median follow-up of 2.5 years. At a median follow-up of 5 years, further decline in the cosmetic outcome was observed in 5 women. Cosmesis at the time of last assessment was 43.3% excellent, 30% good, 20% fair, and 6.7% poor. Fibrosis according to CTCAE at last assessment was 3.3% grade 2 toxicity and 0% grade 3 toxicity. There was no correlation of CTCAE grade 2 or greater fibrosis with cosmesis. The 5-year rate of local control was 97% for all 34 patients initially enrolled. CONCLUSIONS In this prospective trial with 5-year median follow-up, we observed an excellent rate of tumor control using IMRT-planned APBI. Cosmetic outcomes, however, continued to decline, with 26.7% of women having a fair to poor cosmetic result. These results underscore the need for continued cosmetic assessment for patients treated with APBI by technique.
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MESH Headings
- Adult
- Aged
- Breast/pathology
- Breast/radiation effects
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Breath Holding
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Dose Fractionation, Radiation
- Early Termination of Clinical Trials
- Esthetics
- Female
- Fibrosis
- Follow-Up Studies
- Humans
- Middle Aged
- Movement
- Prospective Studies
- Radiation Injuries/pathology
- Radiotherapy, Intensity-Modulated/adverse effects
- Radiotherapy, Intensity-Modulated/methods
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Affiliation(s)
- Adam L Liss
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Merav A Ben-David
- Department of Radiation Oncology, The Sheba Medical Center, Ramat Gan, Israel
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kent A Griffith
- Biostatistics Unit, University of Michigan, Ann Arbor, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Robin B Marsh
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
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Russo AL, Taghian AG. Fat necrosis of the breast in the accelerated partial breast irradiation era: the need for a universal grading system. Breast Cancer Res Treat 2014; 140:1-11. [PMID: 23797180 DOI: 10.1007/s10549-013-2611-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 06/11/2013] [Indexed: 12/01/2022]
Abstract
Fat necrosis of the breast is increasingly reported and used as a trial endpoint in the treatment of breast cancer with accelerated partial breast irradiation (APBI). Yet, there is no universal toxicity scoring system within the latest version of the Common Terminology Criteria for Adverse Events (CTCAE v4.0). This requires investigators to adopt their own scoring system or improperly use those that exist, and limits accurate reporting of this entity. Fat necrosis of the breast also creates diagnostic uncertainty among clinicians and concern of recurrence among patients. In this review, we address the question of increasing incidence of fat necrosis through the comparison of recent APBI trials and literature. The pathogenesis, symptoms, clinical and radiologic diagnosis, clinical predictors of developing fat necrosis, management and follow-up are also discussed.Lastly, we propose a simplified and universal scoring system for the reporting of fat necrosis.
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49
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Five-Year Outcomes, Cosmesis, and Toxicity With 3-Dimensional Conformal External Beam Radiation Therapy to Deliver Accelerated Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2013; 87:1051-7. [DOI: 10.1016/j.ijrobp.2013.08.046] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/12/2013] [Accepted: 08/27/2013] [Indexed: 01/29/2023]
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50
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Accelerated partial breast irradiation using 3D conformal radiotherapy: Toxicity and cosmetic outcome. Breast 2013; 22:1136-41. [DOI: 10.1016/j.breast.2013.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 06/19/2013] [Accepted: 07/16/2013] [Indexed: 11/17/2022] Open
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