RESUMEN
PURPOSE: Up to 50% of women treated for localized breast cancer will experience some degree of arm or shoulder morbidity. Although radiation is thought to contribute to this morbidity, the mechanism remains unclear. Prior studies have shown biologic and radiographic changes in the pectoralis muscles after radiation. This study thus aimed to investigate the relationship between radiation to the pectoralis muscles and referrals for rehabilitation services posttreatment for arm and shoulder morbidity. METHODS AND MATERIALS: A retrospective 1:1 matched case-control study was conducted for patients with breast cancer who were and were not referred for breast or shoulder rehabilitation services between 2014 and 2019 at a single academic institution. Patients were included if they had a lumpectomy and adjuvant radiation. Patients who underwent an axillary lymph node dissection were excluded. Cohorts were matched based on age, axillary surgery, and use of radiation boost. Muscle doses were converted to equivalent dose in 2 Gy fractions assuming an α:ß ratio of 2.5 and were compared between the 2 groups. RESULTS: In our cohort of 50 patients of a median age 60 years (interquartile range, 53-68 years), 36 patients (72%) underwent a sentinel lymph node biopsy in addition to a lumpectomy. Although pectoralis muscle doses were generally higher in those receiving rehabilitation services, this was not statistically significant. Pectoralis major V20-40 Gy reached borderline significance, as did pectoralis major mean dose (17.69 vs 20.89 Gy; P = .06). CONCLUSIONS: In this limited cohort of patients, we could not definitively conclude a relationship between pectoralis muscle doses and use of rehabilitation services. Given the borderline significant findings, this should be further investigated in a larger cohort.
Asunto(s)
Neoplasias de la Mama , Humanos , Femenino , Persona de Mediana Edad , Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Neoplasias de la Mama/patología , Músculos Pectorales/patología , Estudios Retrospectivos , Estudios de Casos y Controles , Biopsia del Ganglio Linfático Centinela , Axila/patologíaRESUMEN
PURPOSE: Limiting cardiac radiation dose is important for minimizing long-term cardiac toxicity in patients with left-sided early-stage breast cancer. METHODS AND MATERIALS: Prospectively collected dosimetric data were analyzed for patients undergoing moderately hypofractionated radiation therapy to the left breast within the Michigan Radiation Oncology Quality Consortium from 2016 to 2022. The mean heart dose (MHD) goal was progressively tightened from ≤2 Gy in 2016 to MHD ≤ 1.2 Gy in 2018. In 2021, a planning target volume (PTV) coverage goal was added, and the goal MHD was reduced to ≤1 Gy. Multivariate logistic regression models were developed to assess for covariates associated with meeting the MHD goals in 2016 to 2020 and the combined MHD/PTV coverage goal in 2021 to 2022. RESULTS: In total, 4165 patients were analyzed with a median age of 64 years. Overall average cardiac metric compliance was 91.7%. Utilization of motion management increased from 41.8% in 2016 to 2020 to 46.5% in 2021 to 2022. Similarly, use of prone positioning increased from 12.2% to 22.2% in these periods. On multivariate analysis in the 2016 to 2020 cohort, treatment with motion management (odds ratio [OR], 5.20; 95% CI, 3.59-7.54; P < .0001) or prone positioning (OR, 3.21; 95% CI, 1.85-5.57; P < .0001) was associated with meeting the MHD goal, while receipt of boost (OR, 0.25; 95% CI, 0.17-0.39; P < .0001) and omission of hormone therapy (OR, 0.65; 95% CI, 0.49-0.88; P = .0047) were associated with not meeting the MHD goal. From 2021 to 2022, treatment with motion management (OR, 1.89; 95% CI, 1.12-3.21; P = .018) or prone positioning (OR, 3.71; 95% CI, 1.73-7.95; P = .0008) was associated with meeting the combined MHD/PTV goal, while larger breast volume (≥1440 cc; OR, 0.34; 95% CI, 0.13-0.91; P = .031) was associated with not meeting the combined goal. CONCLUSIONS: In our statewide consortium, high rates of compliance with aggressive targets for limiting cardiac dose were achievable without sacrificing target coverage.
Asunto(s)
Neoplasias de la Mama , Neoplasias de Mama Unilaterales , Humanos , Persona de Mediana Edad , Femenino , Dosificación Radioterapéutica , Neoplasias de Mama Unilaterales/radioterapia , Reducción Gradual de Medicamentos , Neoplasias de la Mama/radioterapia , Corazón , Planificación de la Radioterapia Asistida por Computador/métodosRESUMEN
OBJECTIVE: There are several obstructive sleep apnea (OSA) treatment options available to patients, including surgery and less invasive therapies. Little is known about the factors that influence patient preferences for treatment. We aimed to understand factors influencing patient experience and decision making for undergoing sleep surgery. STUDY DESIGN: Retrospective qualitative study. SETTING: Tertiary sleep surgery clinic. METHODS: We conducted semistructured interviews with adults who previously underwent any nasal and/or pharyngeal sleep surgery. We asked open-ended questions about their decision-making process within a preconceived thematic framework of chief OSA symptoms, expectations for recovery, and sources of information. The interviews were audio recorded and transcribed, and content was analyzed for defined, emergent, and prevalent themes. RESULTS: Ten patients were interviewed from December 11, 2020 through January 29, 2021. Six patients underwent nasal surgery, 1 underwent pharyngeal surgery, and 3 underwent staged nasal and pharyngeal procedures. All patients were beyond the acute recovery phase. Reasons for pursuing surgical consultation varied from sleep apnea burden to external factors, such as recommendations from significant others. Duration of sleep surgery consideration varied from months to years. Major concerns about sleep surgery involved anesthesia and postoperative pain. External factors influencing patients' decisions to pursue sleep surgery included family and friend support. Postoperative outcomes of surgery included patient satisfaction with decision for surgery, given OSA improvements. CONCLUSION: Understanding patient factors that influence decision making for sleep surgery may guide clinicians in patient-centered counseling that engages patients in decision making, aligning with clinical symptoms and patient preferences.
Asunto(s)
Síndromes de la Apnea del Sueño , Apnea Obstructiva del Sueño , Adulto , Humanos , Estudios Retrospectivos , Apnea Obstructiva del Sueño/diagnóstico , Faringe/cirugía , SueñoRESUMEN
STUDY OBJECTIVES: Physician-patient interactions influence the immediate encounter and leave lasting impressions for future health care encounters. We aimed to understand patient experiences and decision-making for considering sleep surgery, in terms of barriers and communication behaviors that facilitate or hinder referral for consideration of sleep surgery management of obstructive sleep apnea (OSA) when continuous positive airway pressure (CPAP) therapy has failed. METHODS: We employed qualitative methods, using semistructured interviews of adults with OSA who presented for sleep surgery consultation after unsatisfactory therapy with CPAP. Open-ended questions traced symptoms and progression of sleep apnea burden, trials of noninvasive OSA therapies, outcomes, and patient expectations and concerns. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes. RESULTS: Ten adult patients with OSA were enrolled March through April 2021 and reached predominant thematic saturation. Barriers to sleep surgery consultation included: (1) delays in OSA diagnosis due to limited OSA awareness among patients or primary providers and patients' perceived inconvenience of sleep testing, (2) patients faulted for slow progress, (3) patient-reported lack of urgency by providers in troubleshooting noninvasive management options, (4) scheduling delays and waitlists, and (5) cost. Patients were receptive to noninvasive treatment options, but inadequate improvement led to frustration after multiple encounters. Patients appreciated empathetic providers who shared information through transparent and understandable explanations and who presented multiple treatment options. CONCLUSIONS: Experiences of patients with OSA highlight the need for shared decision-making through improved communication of unresolved concerns and alternative management options, including timely referral for sleep surgery consultation when indicated. CITATION: Ikeda AK, McShay C, Marsh R, et al. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives. J Clin Sleep Med. 2023;19(1):111-117.
Asunto(s)
Comunicación , Accesibilidad a los Servicios de Salud , Relaciones Médico-Paciente , Derivación y Consulta , Apnea Obstructiva del Sueño , Adulto , Humanos , Presión de las Vías Aéreas Positiva Contínua , Derivación y Consulta/estadística & datos numéricos , Apnea Obstructiva del Sueño/cirugía , Apnea Obstructiva del Sueño/terapia , Insuficiencia del TratamientoRESUMEN
PURPOSE: Locally advanced lung cancer (LALC) treatment planning is often complex due to challenging tradeoffs related to large targets near organs at risk, making the judgment of plan quality difficult. The purpose of this work was to update and maintain a multi-institutional knowledge-based planning (KBP) model developed by a statewide consortium of academic and community practices for use as a plan quality assurance (QA) tool. METHODS AND MATERIALS: Sixty LALC volumetric-modulated arc therapy plans from 2021 were collected from 24 institutions. Plan quality was scored, with high-quality clinical (HQC) plans selected to update a KBP model originally developed in 2017. The model was validated via automated KBP planning, with 20 cases excluded from the model. Differences in dose-volume histogram metrics in the clinical plans, 2017 KBP model plans, and 2022 KBP model plans were compared. Twenty recent clinical cases not meeting consortium quality metrics were replanned with the 2022 model to investigate potential plan quality improvements. RESULTS: Forty-seven plans were included in the final KBP model. Compared with the clinical plans, the 2022 model validation plans improved 60%, 65%, and 65% of the lung V20Gy, mean heart dose, and spinal canal D0.03cc metrics, respectively. The 2022 model showed improvements from the 2017 model in hot spot management at the cost of greater lung doses. Of the 20 recent cases not meeting quality metrics, 40% of the KBP model-replanned cases resulted in acceptable plans, suggesting potential clinical plan improvements. CONCLUSIONS: A multi-institutional KBP model was updated using plans from a statewide consortium. Multidisciplinary plan review resulted in HQC model training plans and model validation resulted in acceptable quality plans. The model proved to be effective at identifying potential plan quality improvements. Work is ongoing to develop web-based training plan review tools and vendor-agnostic platforms to provide the model as a QA tool statewide.
Asunto(s)
Neoplasias Pulmonares , Radioterapia de Intensidad Modulada , Humanos , Órganos en Riesgo , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador/métodos , Neoplasias Pulmonares/radioterapia , Radioterapia de Intensidad Modulada/métodos , PulmónRESUMEN
PURPOSE: Simple intensity modulation of radiation therapy reduces acute toxicity compared with 2-dimensional techniques in adjuvant breast cancer treatment, but it remains unknown whether more complex or inverse-planned intensity modulated radiation therapy (IMRT) offers an advantage over forward-planned, 3-dimensional conformal radiation therapy (3DCRT). METHODS AND MATERIALS: Using prospective data regarding patients receiving adjuvant whole breast radiation therapy without nodal irradiation at 23 institutions from 2011 to 2018, we compared the incidence of acute toxicity (moderate-severe pain or moist desquamation) in patients receiving 3DCRT versus IMRT (either inverse planned or, if forward-planned, using ≥5 segments per gantry angle). We evaluated associations between technique and toxicity using multivariable models with inverse-probability-of-treatment weighting, adjusting for treatment facility as a random effect. RESULTS: Of 1185 patients treated with 3DCRT and conventional fractionation, 650 (54.9%) experienced acute toxicity; of 774 treated with highly segmented forward-planned IMRT, 458 (59.2%) did; and of 580 treated with inverse-planned IMRT, 245 (42.2%) did. Of 1296 patients treated with hypofractionation and 3DCRT, 432 (33.3%) experienced acute toxicity; of 709 treated with highly segmented forward-planned IMRT, 227 (32.0%) did; and of 623 treated with inverse-planned IMRT, 164 (26.3%) did. On multivariable analysis with inverse-probability-of-treatment weighting, the odds ratio for acute toxicity after inverse-planned IMRT versus 3DCRT was 0.64 (95% confidence interval, 0.45-0.91) with conventional fractionation and 0.41 (95% confidence interval, 0.26-0.65) with hypofractionation. CONCLUSIONS: This large, prospective, multicenter comparative effectiveness study found a significant benefit from inverse-planned IMRT compared with 3DCRT in reducing acute toxicity of breast radiation therapy. Future research should identify the dosimetric differences that mediate this association and evaluate cost-effectiveness.
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Neoplasias de la Mama , Radioterapia Conformacional , Radioterapia de Intensidad Modulada , Neoplasias de la Mama/etiología , Neoplasias de la Mama/radioterapia , Femenino , Humanos , Estudios Prospectivos , Planificación de la Radioterapia Asistida por Computador/métodos , Radioterapia Conformacional/efectos adversos , Radioterapia Conformacional/métodos , Radioterapia de Intensidad Modulada/efectos adversos , Radioterapia de Intensidad Modulada/métodosRESUMEN
PURPOSE: Radiation therapy (RT) can increase the risk of cardiac events in patients with breast cancer (BC), but biomarkers predicting risk for developing RT-induced cardiac disease are currently lacking. We report results from a prospective clinical trial evaluating early magnetic resonance imaging (MRI) and serum biomarker changes as predictors of cardiac injury and risk of subsequent cardiac events after RT for left-sided disease. METHODS: Women with node-negative and node-positive (N-/+) left-sided BC were enrolled on 2 institutional review board (IRB)-approved protocols at 2 institutions. MRI was conducted pretreatment (within 1 week of starting radiation), at the end of treatment (last day of treatment ±1 week), and 3 months after the last day of treatment (±2 weeks) to quantify left and right ventricular volumes and function, myocardial fibrosis, and edema. Perfusion changes during regadenoson stress perfusion were also assessed on a subset of patients (n = 28). Serum was collected at the same time points. Whole heart and cardiac substructures were contoured using CT and MRI. Models were constructed using baseline cardiac and clinical risk factors. Associations between MRI-measured changes and dose were evaluated. RESULTS: Among 51 women enrolled, mean heart dose ranged from 0.80 to 4.7 Gy and mean left ventricular (LV) dose from 1.1 to 8.2 Gy, with mean heart dose 2.0 Gy. T1 time, a marker of fibrosis, and right ventricular (RV) ejection fraction (EF) significantly changed with treatment; these were not dose dependent. T2 (marker of edema) and LV EF did not significantly change. No risk factors were associated with baseline global perfusion. Prior receipt of doxorubicin was marginally associated with decreased myocardial perfusion after RT (P = .059), and mean MHD was not associated with perfusion changes. A significant correlation between baseline IL-6 and mean heart dose (MHD) at the end of RT (ρ 0.44, P = .007) and a strong trend between troponin I and MHD at 3 months post-treatment (ρ 0.33, P = .07) were observed. No other significant correlations were identified. CONCLUSIONS: In this prospective study of women with left-sided breast cancer treated with contemporary treatment planning, cardiac radiation doses were very low relative to historical doses reported by Darby et al. Although we observed significant changes in T1 and RV EF shortly after RT, these changes were not correlated with whole heart or substructure doses. Serum biomarker analysis of cardiac injury demonstrates an interesting trend between markers and MHD that warrants further investigation.
Asunto(s)
Neoplasias de la Mama , Cardiotoxicidad , Biomarcadores , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/patología , Neoplasias de la Mama/radioterapia , Cardiotoxicidad/diagnóstico por imagen , Cardiotoxicidad/etiología , Femenino , Corazón/diagnóstico por imagen , Humanos , Imagen por Resonancia Magnética , Estudios ProspectivosRESUMEN
PURPOSE: To assess the accuracy of dose calculations in the near-surface region for different treatment planning systems (TPSs), treatment techniques, and energies to improve clinical decisions for patients receiving whole breast irradiation (WBI). METHODS AND MATERIALS: A portable custom breast phantom was designed for dose measurements in the near-surface regions. Treatment plans of varying complexities were created at 8 institutions using 4 different TPSs on an anonymized patient data set (50 Gy in 25 fractions) and peer reviewed by participants. The plans were recalculated on the phantom data set. The phantom was aligned with predetermined shifts and laser marks or cone beam computed tomography, and the irradiation was performed using a variety of linear accelerators at the participating institutions. Dose was measured with radiochromic film placed at 0.5 and 1.0 cm depth and 3 locations per depth within the phantom. The film was scanned and analyzed >24 hours postirradiation. RESULTS: The percentage difference between the mean of the measured and calculated dose across the participating centers was -0.2 % ± 2.9%, with 95% of measurements within 6% agreement. No significant differences were found between the mean of the calculated and measured dose for all TPSs, treatment techniques, and energies at all depths and laterality investigated. Furthermore, no significant differences were observed between the mean of measured dose and the prescription dose of 2 Gy per fraction. CONCLUSION: These results demonstrate that dose calculations for clinically relevant WBI plans are accurate to within 6% of measurements in the near-surface region for various complexities, TPSs, linear accelerators, and beam energies. This work lays the necessary foundation for future studies investigating the correlation between near-surface dose and acute skin toxicities.
Asunto(s)
Aceleradores de Partículas , Planificación de la Radioterapia Asistida por Computador , Humanos , Fantasmas de Imagen , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador/métodosRESUMEN
Breast-conserving surgery (BCS) and radiotherapy reduce breast cancer recurrence but can cause functional deficits in breast cancer survivors. A cross-sectional study quantified the long-term pathophysiological impact of these treatments on biomechanical measures of shoulder stiffness and ultrasound shear wave elastography measures of the shear elastic modulus of the pectoralis major (PM). Nine node-positive patients treated with radiotherapy to the breast and regional nodes after BCS and axillary lymph node dissection (Group 1) were compared to nine node-negative patients treated with radiotherapy to the breast alone after BCS and sentinel node biopsy (Group 2) and nine healthy age-matched controls. The mean follow-up for Group 1 and Group 2 patients was 988 days and 754 days, respectively. Shoulder stiffness did not differ between the treatment groups and healthy controls (p = 0.23). The PM shear elastic modulus differed between groups (p = 0.002), with Group 1 patients exhibiting a stiffer PM than Group 2 patients (p < 0.001) and healthy controls (p = 0.027). The mean prescribed radiotherapy dose to the PM was significantly correlated with passive shear elastic modulus (p = 0.018). Breast cancer patients undergoing more extensive axillary surgery and nodal radiotherapy did not experience long-term functional deficits to shoulder integrity but did experience long-term mechanical changes of the PM.
Asunto(s)
Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Músculos Pectorales/fisiopatología , Hombro/fisiopatología , Adulto , Anciano , Fenómenos Biomecánicos , Neoplasias de la Mama/fisiopatología , Estudios Transversales , Módulo de Elasticidad , Femenino , Humanos , Mastectomía Segmentaria , Persona de Mediana Edad , Músculos Pectorales/efectos de la radiación , Músculos Pectorales/cirugía , Hombro/efectos de la radiación , Hombro/cirugíaRESUMEN
PURPOSE: Although previous work demonstrated superior dose distributions for left-sided breast cancer patients planned for intensity-modulated radiation therapy (IMRT) at deep inspiration breath hold compared with conventional techniques with free-breathing, such techniques are not always feasible to limit the impact of respiration on treatment delivery. This study assessed whether optimization based on multiple instance geometry approximation (MIGA) could derive an IMRT plan that is less sensitive to known respiratory motions. METHODS AND MATERIALS: CT scans were acquired with an active breathing control device at multiple breath-hold states. Three inverse optimized plans were generated for eight left-sided breast cancer patients: one static IMRT plan optimized at end exhale, two (MIGA) plans based on a MIGA representation of normal breathing, and a MIGA representation of deep breathing, respectively. Breast and nodal targets were prescribed 52.2 Gy, and a simultaneous tumor bed boost was prescribed 60 Gy. RESULTS: With normal breathing, doses to the targets, heart, and left anterior descending (LAD) artery were equivalent whether optimizing with MIGA or on a static data set. When simulating motion due to deep breathing, optimization with MIGA appears to yield superior tumor-bed coverage, decreased LAD mean dose, and maximum heart and LAD dose compared with optimization on a static representation. CONCLUSIONS: For left-sided breast-cancer patients, inverse-based optimization accounting for motion due to normal breathing may be similar to optimization on a static data set. However, some patients may benefit from accounting for deep breathing with MIGA with improvements in tumor-bed coverage and dose to critical structures.
Asunto(s)
Neoplasias de la Mama/radioterapia , Planificación de la Radioterapia Asistida por Computador/métodos , Radioterapia de Intensidad Modulada/métodos , Respiración , Aorta Torácica , Neoplasias de la Mama/diagnóstico por imagen , Neoplasias de la Mama/patología , Corazón/efectos de la radiación , Humanos , Movimiento , Dosificación Radioterapéutica , Radioterapia de Intensidad Modulada/normas , Tomografía Computarizada por Rayos X/métodos , Carga TumoralRESUMEN
Skin dose assessment for chest wall radiotherapy is important to ensure sufficient dose to the surface target volume without excessive skin reaction. This study quantified changes to the surface doses as a function of bolus material for conventional and intensity modulated radiation therapy (IMRT) tangential fields. Three types of bolus materials (2 mm solid, 2 mm fine mesh and 3.2 mm large mesh Aquaplast) were compared with Superflab. Surface dose measurements were performed using an Attix parallel plate chamber in a flat solid water phantom at 0 degrees , 45 degrees and 70 degrees incident angles. Over-response correction factors were applied to the Attix chamber results for different incident angles. Surface dose measurements on an anthropomorphic phantom were done using a thermoluminescent dosimeter extrapolation method. Dose characteristics of Superflab and solid Aquaplast were within 2% of solid water material. No significant differences (within 3%) in the surface dose were found between conventional and IMRT tangential techniques. The bolus effect was large for chest wall tangential radiotherapy, with up to an 82% increase using 2 mm fine mesh Aquaplast. The dosimetric effect of different Aquaplast materials has been quantified in this work. These materials can be used to create a custom bolus with potentially better reproducibility of placement.
Asunto(s)
Mama/efectos de la radiación , Dosis de Radiación , Piel/efectos de la radiación , Pared Torácica/efectos de la radiación , Humanos , Fantasmas de Imagen , Dosificación Radioterapéutica , Radioterapia de Intensidad Modulada , Sensibilidad y Especificidad , Propiedades de Superficie , Dosimetría TermoluminiscenteRESUMEN
In Spring 2015, a series of earthquakes and aftershocks struck Nepal. The earthquakes caused significant changes in labor and land availability, cash income needs, and land quality. We examine how these post-earthquake impacts converged with ongoing agricultural shifts. Earthquake-related socio-economic and landscape changes specifically motivate the adoption of cardamom, Amomum subulatum, a high-value ecologically beneficial, and low labor commercial crop. We investigate reasons for the increased interest in cardamom post-earthquake, and challenges associated with it. We find that adopting cardamom serves as an important post-disaster adaptation. However, more broadly, unevenly distributed interventions coupled with the high capital costs of agricultural transition exacerbate social differentiation in communities after the disaster. Adoption is often limited to economically better off smallholder farmers. This paper extends previous research on disasters and smallholder farming by highlighting the specific potential of disasters to accelerate agricultural transitions and resulting inequality from the changes.
Asunto(s)
Agricultura/economía , Agricultura/tendencias , Productos Agrícolas/economía , Desastres , Terremotos , Elettaria , Especias/economía , Agricultores/psicología , Femenino , Bosques , Humanos , Renta , Masculino , Nepal , Pobreza/prevención & control , Salarios y Beneficios/economía , Calidad del Agua , Recursos HídricosRESUMEN
PURPOSE: To use knowledge-based planning (KBP) as a method of producing high-quality, consistent, protocol-compliant treatment plans in a complex setting of spine stereotactic body radiation therapy on NRG Oncology Radiation Therapy Oncology Group (RTOG) 0631. METHODS AND MATERIALS: An internally developed KBP model was applied to an external validation cohort of 22 anonymized cases submitted under NRG Oncology RTOG 0631. The original and KBP plans were compared via their protocol compliance, target conformity and gradient index, dose to critical structures, and dose to surrounding normal tissues. RESULTS: The KBP model generated plans meeting all protocol objectives in a single optimization when tested on both internal and protocol-submitted NRG Oncology RTOG 0631 cases. Two submitted plans that were considered to have a protocol-unacceptable deviation were made protocol compliant through the use of the model. There were no statistically significant differences in protocol spinal cord metrics (D10% and D0.03cc) between the manually optimized plans and the KBP plans. The volume of planning target volume receiving prescription dose increased from 93.3% ± 3.2% to 98.3% ± 1.4% (P = .01) when using KBP. High-dose spillage to surrounding normal tissues (V105%) showed no significant differences (2.1 ± 7.3 cm3 for manual plans to 1.8 ± 0.6 cm3 with KBP), and dosimetric outliers with large amounts of spillage were eliminated through the use of KBP. Knowledge-based planning plans were also found to be significantly more consistent in several metrics, including target coverage and high dose outside of the target. CONCLUSION: Incorporation of KBP models into the clinical trial setting may have a profound impact on the quality of trial results, owing to the increase in consistency and standardization of planning, especially for treatment sites or techniques that are nonstandard.
Asunto(s)
Mejoramiento de la Calidad/normas , Oncología por Radiación/normas , Radiocirugia/normas , Planificación de la Radioterapia Asistida por Computador/normas , Radioterapia de Intensidad Modulada/normas , Neoplasias de la Columna Vertebral/radioterapia , Cauda Equina/diagnóstico por imagen , Ensayos Clínicos como Asunto , Humanos , Bases del Conocimiento , Órganos en Riesgo/diagnóstico por imagen , Calidad de Vida , Dosificación Radioterapéutica , Efectividad Biológica Relativa , Neoplasias de la Columna Vertebral/diagnóstico por imagen , Columna Vertebral/diagnóstico por imagenRESUMEN
PURPOSE: Although inverse-planned intensity modulated radiotherapy (IMRT) and deep inspiration breath hold (DIBH) may allow for more conformal dose distributions, it is unknown whether using these technologies reduces cardiac or pulmonary toxicity of breast radiotherapy. METHODS AND MATERIALS: A randomized controlled trial compared IMRT-DIBH versus standard, free-breathing, forward-planned, three-dimensional conformal radiotherapy in patients with left-sided, node-positive breast cancer in whom the internal mammary nodal region was targeted. Endpoints included dosimetric parameters and changes in pulmonary and cardiac perfusion and function, measured by single photon emission computed tomography (SPECT) scans and pulmonary function testing performed at baseline and 1 year post treatment. RESULTS: Of 62 patients randomized, 54 who completed all follow-up procedures were analyzed. Mean doses to the ipsilateral lung, left ventricle, whole heart, and left anterior descending coronary artery were lower with IMRT-DIBH; the percent of left ventricle receiving ≥5 Gy averaged 15.8% with standard radiotherapy and 5.6% with IMRT-DIBH (P < .001). SPECT revealed no differences in perfusion defects in the left anterior descending coronary artery territory, the study's primary endpoint, but did reveal statistically significant differences (P = .02) in left ventricular ejection fraction (LVEF), a secondary endpoint. No differences were found for lung perfusion or function. CONCLUSION: The small but statistically significant benefit in preservation of cardiac LVEF observed here should motivate future studies that include LVEF as a potentially meaningful endpoint. Future studies should disaggregate the impact of IMRT from that of DIBH. Clinical practice should recognize the importance of minimizing cardiac dose, even when already low in comparison to historical levels.
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Neoplasias de la Mama/radioterapia , Radioterapia/métodos , Adulto , Anciano , Algoritmos , Neoplasias de la Mama/patología , Contencion de la Respiración , Femenino , Humanos , Pulmón/patología , Ganglios Linfáticos/patología , Metástasis Linfática , Persona de Mediana Edad , Perfusión , Traumatismos por Radiación , Radiometría , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador , Radioterapia Conformacional , Radioterapia de Intensidad Modulada , Pruebas de Función Respiratoria , Tomografía Computarizada de Emisión de Fotón Único , Resultado del TratamientoRESUMEN
PURPOSE: 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. METHODS AND MATERIALS: 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. RESULTS: 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. CONCLUSIONS: 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.
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Neoplasias de la Mama/radioterapia , Corazón , Movimiento , Respiración , Adulto , Neoplasias de la Mama/diagnóstico por imagen , Femenino , Corazón/diagnóstico por imagen , Humanos , Persona de Mediana Edad , Reproducibilidad de los Resultados , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: The short-term displacement and reproducibility of the breast or chest wall, and the internal mammary (IM), infraclavicular (ICV), and supraclavicular (SCV) nodal regions have been assessed as a function of breath-hold state using an active breathing control (ABC) device for patients receiving loco-regional breast radiation therapy. METHODS AND MATERIALS: Ten patients underwent computed tomographic scanning using an ABC device at breath-hold states of end-exhale and 20%, 40%, 60%, and 80% of vital capacity (VC). Patients underwent scanning before treatment and at one third and two thirds of the way through treatment. A regional registration was performed for each target using a rigid-body transformation with mutual information as a metric. RESULTS: Between exhale and 40% of VC, the mean displacement was 0.27/0.34, 0.24/0.31, 0.22/0.19, and 0.13/0.19 cm anterior/superior for the breast or chest wall, and IM, ICV, and SCV nodes, respectively. At 80% of VC, the mean displacement from exhale was 0.84/.88, 0.76/.79, 0.70/0.79, and 0.54/0.56 cm anterior/superior for the breast or chest wall, and IM, ICV, and SCV nodes, respectively. The short-term reproducibility (standard deviation) was <0.3 and Asunto(s)
Neoplasias de la Mama/radioterapia
, Mama
, Ganglios Linfáticos
, Movimiento
, Respiración
, Pared Torácica
, Neoplasias de la Mama/diagnóstico por imagen
, Femenino
, Corazón
, Humanos
, Radiografía
, Reproducibilidad de los Resultados
RESUMEN
PURPOSE: Regional nodal irradiation, including radiation therapy (RT) to the internal mammary node (IMN) region, improves oncologic outcomes in patients with node-positive breast cancer. Concern remains, however, given the proximity of the IMNs to the heart and the association between cardiac RT exposure and toxicity. The objective of the study was to evaluate rates of ischemic cardiac events (ICEs) and associated risk with treatment of the IMN region. METHODS AND MATERIALS: The cardiac outcomes of 2126 patients treated with adjuvant breast RT or breast and nodal RT from 1984 to 2007 at a single institution were reviewed. The primary endpoint was an ICE following RT initiation. The association between IMN RT and ICEs was assessed using Cox proportional hazards models. Treatment with both IMN RT and 3-dimensional (3D) conformal radiation therapy (CRT) began in 1997; therefore, subset analyses of patients with only 3D CRT were performed to minimize bias associated with improved treatment technique. RESULTS: The median follow-up period was 9.3 years. An ICE occurred in 87 patients (4.1%). No increased 10-year rate of ICEs was observed with IMN RT compared with no IMN RT in the total cohort (3.2% [95% confidence interval (CI), 2.4%-4.3%] vs 3.4% [95% CI, 1.5%-7.5%]; hazard ratio [HR], 0.88; P=.73). Similarly, no statistically significant difference was noted in the 3D CRT-planned, left-sided disease subset (5.1% [95% CI, 1.8%-14.1%] vs 4.0% [95% CI, 2.0%-8.0%]; HR, 1.18, P=.76). On multivariate analysis, adjusting for cardiac risk factor imbalances, no significantly increased hazard was noted with IMN RT (HR, 1.84; P=.28) in the 3D CRT-planned, left-sided disease subset. CONCLUSIONS: No statistically significant association between IMN RT and ICEs was demonstrated in a review of patients treated at a single institution from 1984 to 2007. Given the long natural history and low overall rate of ICEs, continued follow-up of this study, as well as additional studies in the 3D CRT era, is warranted to confirm these results. Minimizing cardiac exposure, when treating a limited IMN field, is critical to limit excess risk of ICEs.
Asunto(s)
Corazón/efectos de la radiación , Irradiación Linfática/métodos , Isquemia Miocárdica/etiología , Traumatismos por Radiación/prevención & control , Planificación de la Radioterapia Asistida por Computador/métodos , Radioterapia Conformacional/métodos , Neoplasias de Mama Unilaterales/radioterapia , Adulto , Femenino , Estudios de Seguimiento , Humanos , Irradiación Linfática/efectos adversos , Metástasis Linfática , Arterias Mamarias , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador/efectos adversos , Radioterapia Adyuvante/efectos adversos , Radioterapia Adyuvante/métodos , Radioterapia Conformacional/efectos adversosRESUMEN
PURPOSE: Planning for spine stereotactic body radiation therapy (SBRT) is time consuming, and differences in planner experience and technique result in discrepancies in plan quality between facilities. Here, knowledge-based planning is analyzed to determine if it may be effective in improving the quality and efficiency of spine SBRT planning. MATERIALS AND METHODS: Thirty-eight spine SBRT cases were collected from the University of Michigan database and inverse planned to deliver 3 10-Gy fractions to the planning target volume (PTV). These plans were used to train a knowledge-based model (model A) using RapidPlan (Varian Medical Systems). The model was evaluated for outliers and validated in 10 independent cases. Each of these cases was manually planned to compare the quality of the model-generated plans with the manual plans. To further test the robustness of the software, 2 additional models (models B and C) were created with intentional outliers resulting from inconsistent contouring. RESULTS: Using models A, B, and C, all 10 generated plans met all dose objectives for modeled organs at risk (OARs) (spinal cord, cord planning risk volume, and esophagus) without user intervention. The target coverage and OAR dose sparing was improved or equivalent to manual planning by an expert dosimetrist; however, manually created plans typically required 1 to 1.5 hours to produce and model-generated plans required only 10 to 15 minutes with minimal human intervention to meet all dose objectives. CONCLUSIONS: The clinical quality of plans produced by RapidPlan were found to improve on or be similar to the manually created plans in terms of normal tissue objectives and PTV dose coverage and could be produced in a fraction of the time. RapidPlan is a robust technique that can improve planning efficiency in spine SBRT while maintaining or potentially improving plan quality and standardization across planners and centers.
Asunto(s)
Simulación por Computador , Tratamientos Conservadores del Órgano/métodos , Radiocirugia/métodos , Planificación de la Radioterapia Asistida por Computador/métodos , Radioterapia de Intensidad Modulada/métodos , Neoplasias de la Médula Espinal/radioterapia , Humanos , Órganos en Riesgo , Dosificación Radioterapéutica , Estudios Retrospectivos , Programas Informáticos , Médula Espinal/efectos de la radiación , Factores de TiempoRESUMEN
PURPOSE: To quantify lung perfusion changes after breast/chest wall radiation therapy (RT) using pre- and post-RT single photon emission computed tomography/computed tomography (SPECT/CT) attenuation-corrected perfusion scans; and correlate decreased perfusion with adjuvant RT dose for breast cancer in a prospective clinical trial. METHODS AND MATERIALS: As part of an institutional review board-approved trial studying the impact of RT technique on lung function in node-positive breast cancer, patients received breast/chest wall and regional nodal irradiation including superior internal mammary node RT to 50 to 52.2 Gy with a boost to the tumor bed/mastectomy scar. All patients underwent quantitative SPECT/CT lung perfusion scanning before RT and 1 year after RT. The SPECT/CT scans were co-registered, and the ratio of decreased perfusion after RT relative to the pre-RT perfusion scan was calculated to allow for direct comparison of SPECT/CT perfusion changes with delivered RT dose. The average ratio of decreased perfusion was calculated in 10-Gy dose increments from 0 to 60 Gy. RESULTS: Fifty patients had complete lung SPECT/CT perfusion data available. No patient developed symptoms consistent with pulmonary toxicity. Nearly all patients demonstrated decreased perfusion in the left lung according to voxel-based analyses. The average ratio of lung perfusion deficits increased for each 10-Gy increment in radiation dose to the lung, with the largest changes in regions of lung that received 50 to 60 Gy (ratio 0.72 [95% confidence interval 0.64-0.79], P<.001) compared with the 0- to 10-Gy region. For each increase in 10 Gy to the left lung, the lung perfusion ratio decreased by 0.06 (P<.001). CONCLUSIONS: In the assessment of 50 patients with node-positive breast cancer treated with RT in a prospective clinical trial, decreased lung perfusion by SPECT/CT was demonstrated. Our study allowed for quantification of lung perfusion defects in a prospective cohort of breast cancer patients for whom attenuation-corrected SPECT/CT scans could be registered directly to RT treatment fields for precise dose estimates.
Asunto(s)
Pulmón/fisiopatología , Pulmón/efectos de la radiación , Radioterapia Conformacional , Radioterapia de Intensidad Modulada , Neoplasias de Mama Unilaterales/radioterapia , Adulto , Anciano , Antineoplásicos/uso terapéutico , Intervalos de Confianza , Femenino , Humanos , Pulmón/diagnóstico por imagen , Pulmón/patología , Ganglios Linfáticos/patología , Mastectomía/estadística & datos numéricos , Mastectomía Segmentaria/estadística & datos numéricos , Persona de Mediana Edad , Periodo Posoperatorio , Estudios Prospectivos , Dosis de Radiación , Planificación de la Radioterapia Asistida por Computador/métodos , Tomografía Computarizada de Emisión de Fotón Único , Neoplasias de Mama Unilaterales/diagnóstico por imagenRESUMEN
PURPOSE: A database in which patient data are compiled allows analytic opportunities for continuous improvements in treatment quality and comparative effectiveness research. We describe the development of a novel, web-based system that supports the collection of complex radiation treatment planning information from centers that use diverse techniques, software, and hardware for radiation oncology care in a statewide quality collaborative, the Michigan Radiation Oncology Quality Consortium (MROQC). METHODS AND MATERIALS: The MROQC database seeks to enable assessment of physician- and patient-reported outcomes and quality improvement as a function of treatment planning and delivery techniques for breast and lung cancer patients. We created tools to collect anonymized data based on all plans. RESULTS: The MROQC system representing 24 institutions has been successfully deployed in the state of Michigan. Since 2012, dose-volume histogram and Digital Imaging and Communications in Medicine-radiation therapy plan data and information on simulation, planning, and delivery techniques have been collected. Audits indicated >90% accurate data submission and spurred refinements to data collection methodology. CONCLUSIONS: This model web-based system captures detailed, high-quality radiation therapy dosimetry data along with patient- and physician-reported outcomes and clinical data for a radiation therapy collaborative quality initiative. The collaborative nature of the project has been integral to its success. Our methodology can be applied to setting up analogous consortiums and databases.