Locoregional Radiotherapy For Breast Cancer Research Articles

Patient-reported symptoms before adjuvant locoregional radiotherapy for breast cancer: triple-negative histology impacts the symptom burden.

Multimodal breast cancer treatment may cause side effects reflected in patient-reported outcomes and/or symptom scores at the time of treatment planning for adjuvant radiotherapy. In our department, all patients have been assessed with the Edmonton Symptom Assessment System (ESAS; aquestionnaire addressing 11major symptoms and wellbeing on anumeric scale of 0-10) at the time of treatment planning since 2016. In this study, we analyzed ESAS symptom severity before locoregional radiotherapy. Retrospective review of 132 patients treated between 2016 and 2021 (all comers in breast-conserving or post-mastectomy settings, different radiotherapy fractionations) was performed. All ESAS items and the ESAS point sum were analyzed to identify subgroups with higher symptom burden and thus need for additional care measures. The biggest patient-reported issues were fatigue, pain, and sleep problems. Patients with triple negative breast cancer reported ahigher symptom burden (mean 30 versus20, p = 0.038). Patients assigned to adjuvant endocrine therapy had the lowest point sum (mean18), followed by those on Her-2-targeting agents without chemotherapy (mean19), those on chemotherapy with or without other drugs (mean26), and those without systemic therapy (mean41), p = 0.007. Those with pathologic complete response after neoadjuvant treatment had significantly lower anxiety scores (mean 0.7 versus1.8, p = 0.03) and atrend towards lower depression scores, p = 0.09. Different surgical strategies, age, and body mass index did not impact on ESAS scores, while the type of adjuvant systemic therapy did. The effect of previous neoadjuvant treatment and unfavorable tumor biology (triple negative) emerged as important factors associated with symptom burden, albeit in different domains. ESAS data may facilitate identification of patients who should be considered for additional supportive measures to alleviate specific symptoms.

Brachial plexus doses in locoregional radiotherapy for breast cancer

Background: Brachial plexopathy is a known issue following axillary radiotherapy in locally advanced breast cancer (LABC). We attempted to adapt Radiation Therapy Oncology Group (RTOG) guidelines on brachial plexus (BP) contouring (head and neck cancer) to breast cancer patients receiving post-mastectomy locoregional radiotherapy (LRRT), to determine (I) feasibility of identifying BP in the treatment position for breast cancer, and (II) radiation therapy dose received by BP with respect to the planned dose. Methods: Planning computed tomography (CT) sets (non-contrast) of 10 LABC patients, who had undergone mastectomy and subsequently completed LRRT including posterior axillary boost, were retrieved. Treatment included chest wall irradiation [50 gray (Gy) in 25 fractions, 6–10 Mega-electronVolt (MeV) electrons, 80–100% isodose], and supraclavicular and axillary RT with an anterior photon field [6 megavolts (MVs), 40 Gy in 20 fractions] and a posterior axillary field (6 MVs, 10 Gy in 5 fractions). Vertebral bodies C5–T1, anterior and middle scalene muscles (MS) were contoured and used as guide to identify probable location of BP. Results: Ten LABC patients received LRRT (50 Gy). Mean ipsilateral BP volume was 13.8 cc. Medians of maximum and mean BP doses were 54.65 and 36.62 Gy, respectively. Mean global dose maximum of the respective plans was 58.83 Gy. Mean BP volume receiving >50 Gy was 27.81% (range, 13.01–51.80%). Conclusions: BP contouring in LABC radiotherapy is feasible, with uncertainty in regions of altered anatomy (C5–6, shoulder). The maximum BP doses always exceeded prescribed dose, and although lower than tolerance dose (66 Gy) should be evaluated to reduce adverse events’ risk. This study establishes the feasibility of following RTOG guidelines for BP contouring even in altered treatment position in breast cancer radiotherapy planned on non-contrast CT scans. BP dose maxima in conventional radiotherapy planning are nearly 18–20% higher than prescription isodoses. Albeit safe in conventional terms, the risk of high doses leading to increased risk of plexopathy warrants consideration especially with regard to relation to tumor boost volumes as well as when using hypofractionated regimens which may be less forgiving for late effects.

Natural progression and clinical significance of incidentally detected pulmonary nodules in radiotherapy planning CT scans of breast cancer patients: a retrospective cohort

AbstractAimIndeterminate pulmonary nodules incidentally detected during radiological imaging completed for radiotherapy planning always creates dilemma for the oncologist. The purpose of this study is to evaluate the clinical significance of pulmonary nodules incidentally detected in patients undergoing locoregional radiotherapy for breast cancer and present a retrospective analysis of the natural progression of such nodules.MethodsA retrospective review of computed tomography scans of breast cancer patients who underwent radiotherapy over a period of 3 years to screen out patients with indeterminate lung nodules was undertaken. This was correlated with the patient and tumour characteristics and the status of the disease at last follow-up.ResultsOf the 132 patients reviewed 28 had indeterminate lung nodules. Of the 28 patients, four had progressive lung nodules on follow-up. Subgroup analyses did not show any significant correlation.Discussion and conclusionOne fifth of patients may present with incidentally detected lung nodules. Multiple nodules, ER negative status and locally advanced breast cancer may point to a higher risk of these nodules progressing to metastatic cancer. There is no indication to stop locoregional therapy in the presence of indeterminate nodules, but close follow-up of high-risk group is recommended.

Long-term functional and radiological pulmonary changes after radiation therapy for breast cancer

Background. We assessed late functional and radiological pulmonary changes in breast cancer patients after a median of 11 years following radiotherapy (RT).Material and methods. Seventy women who received adjuvant loco-regional RT for breast cancer during November 1994–May 1998 accepted to participate in this follow-up study. Pulmonary function tests (PFTs) (n = 56) were compared to pre-RT examinations and diagnostic computer tomography (CT) of the lungs (n = 70) were performed and compared to four months post-RT examinations.Result. The median-matched vital capacity (VC), forced expiratory volume in one second (FEV1), and total lung capacity (TLC) were reduced 15%, 9%, and 7%, respectively, at the long-term follow-up (p < 0.001). We could not, however, detect a correlation between ipsilateral V20 and VC-changes. Diffusion capacity (DLCO) appeared to improve compared with the pre-RT baseline level probably due to transient chemotherapy-induced toxicity. The median-matched percentage of the predicted DLCO 11 years after RT was, however, only 86%, indicating a chronic therapy-induced reduction also of this metric. According to the Arriagada classification, ipsilateral V20 and long-term CT-changes showed a significant correlation (rs: 0. 57; p < 0.001) in a small subset of the women.Conclusion. A chronic clinically significant reduction of PFTs compared to pre-RT values and CT-changes four months after RT were still detectable after a median follow-up of 11 years. There was a statistical correlation between V20 and abnormalities on CT but no statistical correlation between V20 and VC-changes.

Arm and shoulder morbidity following surgery and radiotherapy for breast cancer

Purpose. To explore the relationship between radiotherapy (RT) dose levels in the arm/shoulder region and arm/shoulder morbidity in breast cancer patients.Material and methods. This study included 183 breast cancer patients who had received locoregional RT with or without chemotherapy and/or hormone treatment during the period 1998–2002. Individual RT dose level, reflected by dose-volume histograms (DVHs), for the shoulder joint and joining structures were obtained from archived CT-based RT plans. Individual median, mean and maximum arm/shoulder RT dose levels were extracted. Arm/shoulder morbidity was assessed 29–58 months after breast cancer treatment using the following clinical endpoints: arm pain, arm stiffness, swollen arm, use of arm, numbness, shoulder flexion and shoulder abduction difference, fibrosis and breast cancer-related lymphedema. The relationship between arm/shoulder RT dose level and these clinical endpoints was assessed by Spearman's correlation and multivariate logistic regression.Results. Ninety-one percent of the included patients had some degree of arm/shoulder morbidity. Neither mean nor maximum RT dose level was associated with clinical endpoints. However, significant correlations (p < 0.05) were found between DVHs and arm stiffness, arm pain, use of arm and shoulder abduction difference, when arm/shoulder RT dose levels were approximately 15 Gy.Conclusions. Three-dimensional conformal locoregional RT for breast cancer results in long-term arm/shoulder morbidity. To minimize this risk, large shoulder volumes receiving RT doses of approximately 15 Gy should be reduced.

Changes in Pulmonary Function Up to 10 Years After Locoregional Breast Irradiation

To evaluate the long-term impact of locoregional breast radiotherapy (RT) on pulmonary function tests (PFTs). This study included 75 women who underwent postoperative locoregional breast RT. PFTs were performed before RT and 3, 6, and 12 months and 8 to 10 years after RT. By use of univariate and multivariate analyses, the impact of treatment- and patient-related factors on late changes in PFTs was evaluated. During the first year after RT, all PFTs significantly worsened at 3 to 6 months after RT (p < 0.05). At 12 months, forced vital capacity (FVC), vital capacity (VC), and forced expiratory volume in 1 second (FEV(1)) recovered almost to baseline values, whereas total lung capacity (TLC) and diffusion capacity of carbon monoxide (DL(CO)) recovered only slightly and were still found to be decreased compared with baseline (p < 0.05). At 8 to 10 years after RT, mean reductions in FEV(1) of 4% (p = 0.03) and in VC, DL(CO), and TLC of 5%, 9%, and 11% (all p < 0.0001), respectively, were observed compared with pre-RT values. On multivariate analysis, tamoxifen use negatively affected TLC at 8 to 10 years after RT (p = 0.033), whereas right-sided irradiation was associated with a late reduction in FEV(1) (p = 0.027). For FEV(1) and DL(CO), an early decrease was predictive for a late decrease (p = 0.003 and p = 0.0009, respectively). The time course of PFT changes after locoregional RT for breast cancer follows a biphasic pattern. An early reduction in PFTs at 3 to 6 months with a partial recovery at 12 months after RT is followed by a late, more important PFT reduction up to 8 to 10 years after RT. Tamoxifen use may have an impact on this late decline in PFTs.

Respiratory Motion of The Heart and Positional Reproducibility Under Active Breathing Control

To reduce cardiotoxicity from breast radiotherapy (RT), innovative techniques are under investigation. Information about cardiac motion with respiration and positional reproducibility under active breathing control (ABC) is necessary to evaluate these techniques. Patients requiring loco-regional RT for breast cancer were scanned by computed tomography using an ABC device at various breath-hold states, before and during treatment. Ten patients were studied. For each patient, 12 datasets were analyzed. Mutual information-based regional rigid alignment was used to determine the magnitude and reproducibility of cardiac motion as a function of breathing state. For each scan session, motion was quantified by evaluating the displacement of a point along the left anterior descending artery (LAD) with respect to its position at end expiration. Long-term positional reproducibility was also assessed. Displacement of the LAD was greatest in the inferior direction, moderate in the anterior direction, and lowest in the left-right direction. At shallow breathing states, the average displacement of LAD position was up to 6 mm in the inferior direction. The maximum displacement in any patient was 2.8 cm in the inferior direction, between expiration and deep-inspiration breath hold. At end expiration, the long-term reproducibility (SD) of the LAD position was 3 mm in the A-P, 6 mm in the S-I, and 4 mm in the L-R directions. At deep-inspiration breath hold, long-term reproducibility was 3 mm in the A-P, 7 mm in the S-I, and 3 mm in the L-R directions. These data demonstrate the extent of LAD displacement that occurs with shallow breathing and with deep-inspiration breath hold. This information may guide optimization studies considering the effects of respiratory motion and reproducibility of cardiac position on cardiac dose, both with and without ABC.

Setup variations in locoregional radiotherapy for breast cancer: an electronic portal imaging study

Recent trials demonstrating a survival benefit with locoregional radiotherapy (LRRT) to the chest wall and regional nodes in women with node-positive breast cancer have led to increased use of complex techniques to match three or more radiation fields, but information on setup reproducibility with LRRT for breast cancer is scarce. This study reports the magnitude and directions of random and systematic deviations in LRRT for breast cancer using an offline electronic portal imaging verification protocol. Electronic portal images (EPIs) of 46 consecutive women treated with LRRT for breast cancer from March 2001 to February 2002 with LRRT were analysed. Comparisons of EPIs to the corresponding digitally reconstructed radiographs were performed offline with anatomy matching. Displacements in mm were recorded in the superior-inferior (SI), medial-lateral (ML), and anterior-posterior (AP) directions. Random errors ranged from 2.0 mm to 2.5 mm for the breast/chest wall tangential treatments and 2.3 mm to 3.9 mm for the supraclavicular nodal treatments. Systematic errors occurred to a greater degree in the AP direction for the tangential fields and in the ML direction for the supraclavicular field. Displacements of > or =10 mm were found in 1.2% of breast/chest wall tangential treatments and in 6.2% of supraclavicular nodal treatments. These data demonstrate that EPI is a useful tool to verify setup reproducibility in LRRT for breast cancer.

96 Set up deviations in locoregional radiotherapy for breast cancer using an offline electronic portal imaging protocol

96 Set up deviations in locoregional radiotherapy for breast cancer using an offline electronic portal imaging protocol

Magnitude and directions of set up deviations in locoregional radiotherapy for breast cancer using an offline electronic portal imaging protocol

Magnitude and directions of set up deviations in locoregional radiotherapy for breast cancer using an offline electronic portal imaging protocol

Pulmonary function following adjuvant chemotherapy and radiotherapy for breast cancer and the issue of three-dimensional treatment planning

Background and purpose: The frequency and grade of pulmonary complications following adjuvant radiotherapy for breast cancer are still debated. This study focuses on loss of pulmonary function. Materials and methods: We have measured the reduction of pulmonary function 5 months following radiotherapy in 144 node-positive stage II breast cancer patients by using pulmonary function tests. Results: No deterioration of pulmonary function was detected among the patients who were treated with local radiotherapy. On the contrary, there was a mean increase in diffusion capacity by 7% ( P=0.004) following radiotherapy, which most likely was explained by the adjuvant chemotherapy administered prior to the baseline pulmonary function tests. Patients undergoing loco-regional radiotherapy showed a mean reduction in diffusion capacity by 5% ( P<0.001) and in vital capacity by 3% ( P=0.001). The subset of patients (9%) who were diagnosed with severe pulmonary complications needing cortisone treatment had significantly larger mean paired differences in vital capacity (−0.446 L, −15% (equivalent to 15 years of normal ageing or the loss of 3/4 of a lung lobe)) compared to the patients who were asymptomatic (−0.084 L) ( P<0.05).When the effects of potential confounding factors and different radiotherapy techniques were tested on the reduction of pulmonary function by stepwise multiple regression analysis, a significant correlation was found only to loco-regional radiotherapy including the lower internal mammary lymph nodes. Conclusions: We conclude that a clinically important reduction of pulmonary function is seen in the subset of patients who are diagnosed with severe pulmonary complication following loco-regional radiotherapy for breast cancer. The results of this study warrant further studies based on individual lung dose volume histograms.

Abnormalities by pulmonary regions studied with computer tomography following local or loco-regional radiotherapy for breast cancer

Abnormalities by pulmonary regions studied with computer tomography following local or loco-regional radiotherapy for breast cancer

The effect of pulmonary function of local and loco-regional irradiation for breast cancer

Eighty-five patients treated with loco-regional radiotherapy to the breast/chest wall and cervico-axillary nodes, and 16 patients treated with local radiotherapy to the breast/chest wall alone for breast cancer were enrolled in a prospective study to measure the effects of treatment on pulmonary function during the acute phase (10 weeks after completing irradiation) and during the late phase (12 months after completing irradiation), Baseline pulmonary function values were obtained from all patients immediately prior to commencing radiotherapy. Twenty-two patients (25.8%) treated with loco-regional radiotherapy developed transient chest symptoms compared with two patients (12.5%) treated with local radiotherapy ( P = 0.11). Patients undergoing loco-regional radiotherapy showed a reduction of mean vital capacity of 0.13 litres (4.2%) ( P < 0.0001) during the acute phase and at 1 year a further decrease occurred ( P = 0.02) so that mean vital capacity was reduced by 0.18 litres (5.8%) ( P < 0.0001) compared to pretreatment values. Mean transfer factor for carbon monoxide (T LCO) was reduced by 0.85 mmol · kPa −1 · min −1 [11.9%] ( P < 0.0001) during the acute phase and remained unchanged at 1 year. Patients undergoing local radiotherapy to the breast/chest wall alone did not show any significant loss of vital capacity but mean T LCO was reduced during the acute phase by 0.65 mmol · kPa −1 · min −1 (8.3%) ( P < 0.002) which remained unchanged at 1 year. No significant association was found between impairment of ventilation or gas transfer and respiratory history, smoking history, concurrent respiratory symptoms, age, side treated or physiological pulmonary function in either the acute or late phase. This study has quantified some of the physiological sequelae following local and loco-regional radiotherapy for breast cancer. There is no evidence to suggest that any of the above factors are relevant to deciding which patients should, or should not, be offered local or loco-regional radiotherapy for breast cancer.