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Title: Initial dosimetric experience using simple three-dimensional conformal external-beam accelerated partial-breast irradiation

Abstract

Purpose: Several accelerated partial-breast irradiation (APBI) techniques are being investigated in patients with early-stage breast cancer. We present our initial experience using three-dimensional conformal radiation therapy (3D-CRT). Methods and Materials: Sixty-one patients with tumors of 2 cm or less and negative axillary nodes were treated with 3D-CRT accelerated partial-breast irradiation (APBI) between August 2003 and March 2005. The prescribed radiation dose was 32 Gy in 4-Gy fractions given twice daily. Efforts were made to minimize the number of beams required to achieve adequate planning target volume (PTV) coverage. Results: A combination of photons and electrons was used in 85% of patients. A three-field technique that consisted of opposed, conformal tangential photons and enface electrons was employed in 43 patients (70%). Nine patients (15%) were treated with a four-field arrangement, which consisted of three photon fields and enface electrons. Mean PTV volumes that received 100%, 95%, and 90% of the prescribed dose were 93% {+-} 7%, 97% {+-} 4%, and 98% {+-} 2%, respectively. Dose inhomogeneity exceeded 10% in only 7 patients (11%). Mean doses to the ipsilateral lung and heart were 1.8 Gy and 0.8 Gy, respectively. Conclusions: Simple 3D-CRT techniques of APBI can achieve appropriate PTV coverage while offeringmore » significant normal-tissue sparing. Therefore, this noninvasive approach may increase the availability of APBI to patients with early-stage breast cancer.« less

Authors:
 [1];  [2];  [2];  [2];  [3];  [3];  [3];  [3];  [4];  [5];  [6];  [2]
  1. Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA (United States). E-mail: ataghian@partners.org
  2. Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA (United States)
  3. Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA (United States)
  4. Department of Breast Pathology, Massachusetts General Hospital, Boston, MA (United States)
  5. Department of Radiation Oncology, Boston Medical Center, Boston, MA (United States)
  6. Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA (United States)
Publication Date:
OSTI Identifier:
20793387
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 64; Journal Issue: 4; Other Information: DOI: 10.1016/j.ijrobp.2005.09.042; PII: S0360-3016(05)02722-7; Copyright (c) 2006 Elsevier Science B.V., Amsterdam, Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; ELECTRONS; HEART; IRRADIATION; LUNGS; MAMMARY GLANDS; NEOPLASMS; PATIENTS; PHOTONS; RADIATION DOSES; RADIOTHERAPY

Citation Formats

Taghian, Alphonse G., Kozak, Kevin R., Doppke, Karen P., Katz, Angela, Smith, Barbara L., Gadd, Michele, Specht, Michelle, Hughes, Kevin, Braaten, Kristina, Kachnic, Lisa A., Recht, Abram, and Powell, Simon N. Initial dosimetric experience using simple three-dimensional conformal external-beam accelerated partial-breast irradiation. United States: N. p., 2006. Web. doi:10.1016/J.IJROBP.2005.0.
Taghian, Alphonse G., Kozak, Kevin R., Doppke, Karen P., Katz, Angela, Smith, Barbara L., Gadd, Michele, Specht, Michelle, Hughes, Kevin, Braaten, Kristina, Kachnic, Lisa A., Recht, Abram, & Powell, Simon N. Initial dosimetric experience using simple three-dimensional conformal external-beam accelerated partial-breast irradiation. United States. doi:10.1016/J.IJROBP.2005.0.
Taghian, Alphonse G., Kozak, Kevin R., Doppke, Karen P., Katz, Angela, Smith, Barbara L., Gadd, Michele, Specht, Michelle, Hughes, Kevin, Braaten, Kristina, Kachnic, Lisa A., Recht, Abram, and Powell, Simon N. Wed . "Initial dosimetric experience using simple three-dimensional conformal external-beam accelerated partial-breast irradiation". United States. doi:10.1016/J.IJROBP.2005.0.
@article{osti_20793387,
title = {Initial dosimetric experience using simple three-dimensional conformal external-beam accelerated partial-breast irradiation},
author = {Taghian, Alphonse G. and Kozak, Kevin R. and Doppke, Karen P. and Katz, Angela and Smith, Barbara L. and Gadd, Michele and Specht, Michelle and Hughes, Kevin and Braaten, Kristina and Kachnic, Lisa A. and Recht, Abram and Powell, Simon N.},
abstractNote = {Purpose: Several accelerated partial-breast irradiation (APBI) techniques are being investigated in patients with early-stage breast cancer. We present our initial experience using three-dimensional conformal radiation therapy (3D-CRT). Methods and Materials: Sixty-one patients with tumors of 2 cm or less and negative axillary nodes were treated with 3D-CRT accelerated partial-breast irradiation (APBI) between August 2003 and March 2005. The prescribed radiation dose was 32 Gy in 4-Gy fractions given twice daily. Efforts were made to minimize the number of beams required to achieve adequate planning target volume (PTV) coverage. Results: A combination of photons and electrons was used in 85% of patients. A three-field technique that consisted of opposed, conformal tangential photons and enface electrons was employed in 43 patients (70%). Nine patients (15%) were treated with a four-field arrangement, which consisted of three photon fields and enface electrons. Mean PTV volumes that received 100%, 95%, and 90% of the prescribed dose were 93% {+-} 7%, 97% {+-} 4%, and 98% {+-} 2%, respectively. Dose inhomogeneity exceeded 10% in only 7 patients (11%). Mean doses to the ipsilateral lung and heart were 1.8 Gy and 0.8 Gy, respectively. Conclusions: Simple 3D-CRT techniques of APBI can achieve appropriate PTV coverage while offering significant normal-tissue sparing. Therefore, this noninvasive approach may increase the availability of APBI to patients with early-stage breast cancer.},
doi = {10.1016/J.IJROBP.2005.0},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 4,
volume = 64,
place = {United States},
year = {Wed Mar 15 00:00:00 EST 2006},
month = {Wed Mar 15 00:00:00 EST 2006}
}
  • Purpose: We compare the dosimetry of two techniques for three-dimensional, conformal, external beam, accelerated partial breast irradiation (3D-CPBI) in the supine position. Methods and Materials: Sixteen patients with Stage I breast cancer had PBI treatment plans generated using the multiple, noncoplanar photon field technique and the three-field, mixed-modality technique. Planning target volumes (PTVs; lumpectomy site plus 1.5-2.0 cm margin) and total dose (32 Gy) were held constant to facilitate dosimetric comparisons. Plans were optimized for conformality and PTV coverage. Results: Mixed-modality plans employed fewer fields than multiple, noncoplanar photon field plans (mean 3.2 vs. 4.1). Both techniques provided comparable PTVmore » coverage and in all cases, 95% of the PTV received 90% of the prescribed dose. Volumes of ipsilateral breast receiving greater than 16 Gy were similar; however, the mean volume of ipsilateral breast receiving 8 Gy was significantly lower for mixed-modality plans (58% vs. 66%). No differences in the volumes of ipsilateral lung or heart receiving greater than 5 Gy were observed, however, the mixed-modality technique delivered 2.5 Gy to larger volumes of these organs. Conclusions: Both techniques for supine position, 3D-CPBI provides excellent normal tissue sparing with adequate PTV coverage. The multiple, noncoplanar photon field technique exposes smaller volumes of ipsilateral lung and heart to low dose radiation at the expense of increased plan complexity and larger irradiated breast volumes.« less
  • Purpose: To compare the dosimetry of proton and photon-electron three-dimensional, conformal, external beam accelerated partial breast irradiation (3D-CPBI). Methods and Materials: Twenty-four patients with fully excised, Stage I breast cancer treated with adjuvant proton 3D-CPBI had treatment plans generated using the mixed-modality, photon-electron 3D-CPBI technique. To facilitate dosimetric comparisons, planning target volumes (PTVs; lumpectomy site plus 1.5-2.0 cm margin) and prescribed dose (32 Gy) were held constant. Plans were optimized for PTV coverage and normal tissue sparing. Results: Proton and mixed-modality plans both provided acceptable PTV coverage with 95% of the PTV receiving 90% of the prescribed dose in allmore » cases. Both techniques also provided excellent dose homogeneity with a dose maximum exceeding 110% of the prescribed dose in only one case. Proton 3D-CPBI reduced the volume of nontarget breast tissue receiving 50% of the prescribed dose by an average of 36%. Statistically significant reductions in the volume of total ipsilateral breast receiving 100%, 75%, 50%, and 25% of the prescribed dose were also observed. The use of protons resulted in small, but statistically significant, reductions in the radiation dose delivered to 5%, 10%, and 20% of ipsilateral and contralateral lung and heart. The nontarget breast tissue dosimetric advantages of proton 3D-CPBI were not dependent on tumor location, breast size, PTV size, or the ratio of PTV to breast volume. Conclusions: Compared to photon-electron 3D-CPBI, proton 3D-CPBI significantly reduces the volume of irradiated nontarget breast tissue. Both approaches to accelerated partial breast irradiation offer exceptional lung and heart sparing.« less
  • Purpose: This prospective study examines the use of three-dimensional conformal external beam radiation therapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI). Four-year data on efficacy, cosmesis, and toxicity are presented. Methods: Patients with Stage O, I, or II breast cancer with lesions <=3 cm, negative margins, and negative nodes were eligible. The 3D-CRT delivered was 38.5 Gy in 3.85 Gy/fraction. Ipsilateral breast, ipsilateral nodal, contralateral breast, and distant failure (IBF, INF, CBF, DF) were estimated using the cumulative incidence method. Disease-free, overall, and cancer-specific survival (DFS, OS, CSS) were recorded. The National Cancer Institute Common Terminology Criteria for Adversemore » Events (version 3) toxicity scale was used to grade acute and late toxicities. Results: Ninety-four patients are evaluable for efficacy. Median patient age was 62 years with the following characteristics: 68% tumor size <1 cm, 72% invasive ductal histology, 77% estrogen receptor (ER) (+), 88% postmenopausal; 88% no chemotherapy and 44% with no hormone therapy. Median follow-up was 4.2 years (range, 1.3-8.3). Four-year estimates of efficacy were IBF: 1.1% (one local recurrence); INF: 0%; CBF: 1.1%; DF: 3.9%; DFS: 95%; OS: 97%; and CSS: 99%. Four (4%) Grade 3 toxicities (one transient breast pain and three fibrosis) were observed. Cosmesis was rated good/excellent in 89% of patients at 4 years. Conclusions: Four-year efficacy, cosmesis, and toxicity using 3D-CRT to deliver APBI appear comparable to other experiences with similar follow-up. However, additional patients, further follow-up, and mature Phase III data are needed to evaluate thoroughly the extent of application, limitations, and complete value of this particular form of APBI.« less
  • Purpose: We analyzed variables associated with long-term toxicity using three-dimensional conformal external beam radiation therapy (3D-CRT) to deliver accelerated partial breast irradiation. Methods and Materials: One hundred patients treated with 3D-CRT accelerated partial breast irradiation were evaluated using Common Terminology Criteria for Adverse Events version 4.0 scale. Cosmesis was scored using Harvard criteria. Multiple dosimetric and volumetric parameters were analyzed for their association with worst and last (W/L) toxicity outcomes. Results: Sixty-two patients had a minimum of 36 months of toxicity follow-up (median follow-up, 4.8 years). The W/L incidence of poor-fair cosmesis, any telangiectasia, and grade {>=}2 induration, volume reduction,more » and pain were 16.4%/11.5%, 24.2%/14.5%, 16.1%/9.7%, 17.7%/12.9%, and 11.3%/3.2%, respectively. Only the incidence of any telangiectasia was found to be predicted by any dosimetric parameter, with the absolute breast volume receiving 5% to 50% of the prescription dose (192.5 cGy-1925 cGy) being significant. No associations with maximum dose, volumes of lumpectomy cavity, breast, modified planning target volume, and PTV, dose homogeneity index, number of fields, and photon energy used were identified with any of the aforementioned toxicities. Non-upper outer quadrant location was associated with grade {>=}2 volume reduction (p = 0.02 W/p = 0.04 L). A small cavity-to-skin distance was associated with a grade {>=}2 induration (p = 0.03 W/p = 0.01 L), a borderline significant association with grade {>=}2 volume reduction (p = 0.06 W/p = 0.06 L) and poor-fair cosmesis (p = 0.08 W/p = 0.09 L), with threshold distances ranging from 5 to 8 mm. Conclusions: No dose--volume relationships associated with long-term toxicity were identified in this large patient cohort with extended follow-up. Cosmetic results were good-to-excellent in 88% of patients at 5 years.« less
  • Purpose: Several recent studies reported that severe late toxicities including soft-tissue fibrosis and fat necrosis are present in patients treated with accelerated partial breast irradiation (APBI) and that these toxicities are associated with the large volume of tissue targeted by high-dose irradiation. The present study was performed to clarify which patients are unsuitable for APBI to avoid late severe toxicities. Methods and Materials: Study subjects comprised 50 consecutive patients with Stage 0-II unilateral breast cancer who underwent breast-conserving surgery, and in whom five or six surgical clips were placed during surgery. All patients were subsequently replanned using three-dimensional conformal radiotherapymore » (3D-CRT) APBI techniques according to the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-39 and Radiation Therapy Oncology Group (RTOG) 0413 protocol. The beam arrangements included mainly noncoplanar four- or five-field beams using 6-MV photons alone. Results: Dose-volume histogram (DVH) constraints for normal tissues according to the NSABP/RTOG protocol were satisfied in 39 patients (78%). Multivariate analysis revealed that only long craniocaudal clip distance (CCD) was correlated with nonoptimal DVH constraints (p = 0.02), but that pathological T stage, anteroposterior clip distance (APD), site of ipsilateral breast (IB) (right/left), location of the tumor (medial/lateral), and IB reference volume were not. DVH constraints were satisfied in 20% of patients with a long CCD ({>=}5.5 cm) and 92% of those with a short CCD (p < 0.0001). Median IB reference volume receiving {>=}50% of the prescribed dose (IB-V{sub 50}) of all patients was 49.0% (range, 31.4-68.6). Multivariate analysis revealed that only a long CCD was correlated with large IB-V{sub 50} (p < 0.0001), but other factors were not. Conclusion: Patients with long CCDs ({>=}5.5 cm) might be unsuitable for 3D-CRT APBI because of nonoptimal DVH constraints and large IB-V{sub 50}.« less