Long-Term Pulmonary Outcomes of a Feasibility Study of Inverse-Planned, Multibeam Intensity Modulated Radiation Therapy in Node-Positive Breast Cancer Patients Receiving Regional Nodal Irradiation.

PURPOSE: Multibeam intensity modulated radiation therapy (IMRT) enhances the therapeutic index by increasing the dosimetric coverage of the targeted tumor tissues while minimizing volumes of adjacent organs receiving high doses of RT. The tradeoff is that a greater volume of lung is exposed to low doses of RT, raising concern about the risk of radiation pneumonitis (RP). METHODS AND MATERIALS: Between July 2010 and January 2013, patients with node-positive breast cancer received inverse-planned, multibeam IMRT to the breast or chest wall and regional nodes, including the internal mammary nodes (IMNs). The primary endpoint was feasibility, predefined by dosimetric treatment planning criteria. Secondary endpoints included the incidence of RP grade 3 or greater and changes in pulmonary function measured with the Common Terminology Criteria for Adverse Events version 3.0 scales, pulmonary function tests and community-acquired pneumonia questionnaires, obtained at baseline and 6 months after IMRT. Clinical follow-up was every 6 months for up to 5 years. RESULTS: Median follow-up was 53.4 months (range, 0-82 months). Of 113 patients enrolled, 104 completed follow-up procedures. Coverage of the breast or chest wall and IMN was comprehensive (median 48.1 Gy and 48.9 Gy, respectively). The median volume of lung receiving a high dose (V20Gy) and a low dose (V5) was 29% and 100%, respectively. The overall rate of respiratory toxicities was 10.6% (11/104), including 1 grade 3 RP event (0.96%). No differences were found in pulmonary function test or community-acquired pneumonia scores after IMRT. The 5-year rates of locoregional recurrence-free, disease-free, and overall survival were 93.2%, 63.6%, and 80.3%, respectively. CONCLUSIONS: Multibeam IMRT in patients with breast cancer receiving regional nodal irradiation was dosimetrically feasible, based on early treatment planning criteria. Despite the large volume of lung receiving low-dose RT, the incidence of grade 3 RP was remarkably low, justifying inverse-planned IMRT as a treatment modality for patients with high-risk breast cancer in whom conventional RT techniques prove inadequate.

Phase II Study of Hemithoracic Intensity-Modulated Pleural Radiation Therapy (IMPRINT) As Part of Lung-Sparing Multimodality Therapy in Patients With Malignant Pleural Mesothelioma.

PURPOSE: We conducted a two-center phase II study to determine the safety of hemithoracic intensity-modulated pleural radiation therapy (IMPRINT) after chemotherapy and pleurectomy-decortication (P/D) as part of a multimodality lung-sparing treatment. PATIENTS AND METHODS: Patients received up to four cycles of pemetrexed plus platinum. If feasible, P/D was performed. Hemithoracic IMPRINT was administered to a planned dose of 50.4 Gy in 28 fractions. The primary end point was the incidence of grade 3 or greater radiation pneumonitis (RP). RESULTS: A total of 45 patients were enrolled; 18 were not evaluable (because of disease progression before radiation therapy [RT], n = 9; refusal of surgery or RT, n = 5; extrapleural pneumonectomy at time of surgery, n = 2; or chemotherapy complications, n = 2). A total of 26 patients received pemetrexed plus cisplatin, 18 received pemetrexed plus carboplatin, and four received a combination. Thirteen patients (28.9%) had a partial response, 15 patients (33.3%) experienced disease progression, one patient died during chemotherapy, and all others had stable disease. Eight patients underwent P/D or an extended P/D, and 13 underwent a partial P/D. A total of 27 patients started IMPRINT (median dose, 46.8 Gy; range, 28.8 to 50.4 Gy) and were evaluable for the primary end point (median follow-up, 21.6 months). Six patients experienced grade 2 RP, and two patients experienced grade 3 RP; all recovered after corticosteroid initiation. No grade 4 or 5 radiation-related toxicities were observed. The median progression-free survival and overall survival (OS) were 12.4 and 23.7 months, respectively; the 2-year OS was 59% in patients with resectable tumors and was 25% in patients with unresectable tumors. CONCLUSIONS: Hemithoracic IMPRINT for malignant pleural mesothelioma (MPM) is safe and has an acceptable rate of RP. Its incorporation with chemotherapy and P/D forms a new lung-sparing treatment paradigm for patients with locally advanced MPM.

Concurrent radiotherapy and ipilimumab immunotherapy for patients with melanoma.

Ipilimumab and radiotherapy are commonly used to treat unresectable and metastatic melanoma. Results from preclinical studies and case reports suggest a biologic interaction between these two treatments. To understand the clinical implications of the interaction, we carried out a retrospective study reviewing records of patients treated with ipilimumab and radiotherapy for melanoma at our institution between 2005 and 2011. The review included details of treatment, response, adverse events (AE), and overall survival (OS). Twenty-nine patients underwent 33 courses of non-brain radiotherapy between their first and last dose of ipilimumab. Immune-related AEs (ir-AEs) were observed in 43% of patients receiving ipilimumab at 10 mg/kg and in 22% of patients receiving 3 mg/kg; the frequency of ir-AEs was not significantly different compared with previous studies of ipilimumab alone. Radiotherapy-related AEs were significantly more common in patients receiving higher doses of radiation. Palliation of symptoms was reported by 77% of patients after radiotherapy. Median OS was 9 and 39 months in patients receiving radiotherapy during induction and maintenance with ipilimumab, respectively. In this retrospective study, concurrent ipilimumab and radiotherapy was neither associated with higher than expected rates of AEs nor did it abrogate palliative effects of radiotherapy or survival benefits of ipilimumab. Further studies to prospectively explore the efficacy of this therapeutic combination are warranted.

Confirmation of skin doses resulting from bolus effect of intervening alpha-cradle and carbon fiber couch in radiotherapy.

In this study, we verified the treatment planning calculations of skin doses with the incorporation of the bolus effect due to the intervening alpha-cradle (AC) and carbon fiber couch (CFC) using radiochromic EBT2 films. A polystyrene phantom (25 × 25 × 15 cm(3)) with six EBT2 films separated by polystyrene slabs, at depths of 0, 0.1, 0.2, 0.5, 1, 1.4 cm, was positioned above an AC, which was ~1 cm thick. The phantom and AC assembly were CT scanned and the CT-images were transferred to the treatment planning system (TPS) for calculations in three scenarios: (A) ignoring AC and CFC, (B) accounting for AC only, (C) accounting for both AC and CFC. A single posterior 10 × 10 cm(2) field, a pair of posterior-oblique 10 × 10 cm(2) fields, and a posterior IMRT field (6 MV photons from a Varian Trilogy linac) were planned. For each radiation field configuration, the same MU were used in all three scenarios in the TPS. Each plan for scenario C was delivered to expose a stack of EBT2 films in the phantom through AC and CFC. In addition, in vivo EBT2 film measurement on a lung cancer patient immobilized with AC undergoing IMRT was also included in this study. Point doses and planar distributions generated from the TPS for the three scenarios were compared with the data from the EBT2 film measurements. For all the field arrangements, the EBT2 film data including the in vivo measurement agreed with the doses calculated for scenario (C), within the uncertainty of the EBT2 measurements (~4%). For the single posterior field (a pair of posterior-oblique fields), the TPS generated doses were lower than the EBT2 doses by 34%, 33%, 31%, 13% (34%, 31%, 31%, 11%) for scenario A and by 27%, 25%, 22%, 8% (25%, 21%, 21%, 6%) for scenario B at the depths of 0, 0.1, 0.2, 0.5 cm, respectively. For the IMRT field, the 2D dose distributions at each depth calculated in scenario C agree with those measured data. When comparing the central axis doses for the IMRT field, we found the TPS generated doses for scenario A (B) were lower than the EBT2 data by 35%, 34%, 31%, 16% (29%, 26%, 23%, 10%) at the depths of 0, 0.1, 0.2, 0.5 cm, respectively. There were no significant differences for the depths of 1.0 and 1.4 cm for all the radiation fields studied. TPS calculation of doses in the skin layers accounting for AC and CFC was verified by EBT2 film data. Ignoring the presence of AC and/or CFC in TPS calculation would significantly underestimate the doses in the skin layers. For the clinicians, as more hypofractionated regimens and stereotactic regimens are being used, this information will be useful to avoid potential serious skin toxicities, and also assist in clinical decisions and report these doses accurately to relevant clinical trials/cooperative groups, such as RTOG.

Prospective assessment of optimal individual position (prone versus supine) for breast radiotherapy: volumetric and dosimetric correlations in 100 patients.

PURPOSE: Damage to heart and lung from breast radiotherapy is associated with increased cardiovascular mortality and lung cancer development. We conducted a prospective study to evaluate which position is best to spare lung and heart from radiotherapy exposure. METHODS AND MATERIALS: One hundred consecutive Stage 0-IIA breast cancer patients consented to participate in a research trial that required two computed tomography simulation scans for planning both supine and prone positions. The optimal position was defined as that which best covered the contoured breast and tumor bed while it minimized critical organ irradiation, as quantified by the in-field heart and lung volume. The trial was designed to plan the first 100 patients in each position to study correlations between in-field volumes of organs at risk and dose. RESULTS: Fifty-three left and 47 right breast cancer patients were consecutively accrued to the trial. In all patients, the prone position was optimal for sparing lung volume compared to the supine setup (mean lung volume reduction was 93.5 cc for right and 103.6 cc for left breast cancer patients). In 46/53 (87%) left breast cancer patients best treated prone, in-field heart volume was reduced by a mean of 12 cc and by 1.8 cc for the other 7/53 (13%) patients best treated supine. As predicted, supine-prone differences in in-field volume and mean dose of heart and lung were highly correlated (Spearman's correlation coefficient for left breast cancer patients was 0.90 for heart and 0.94 for lung and 0.92 for right breast cancer patients for lung). CONCLUSIONS: Prone setup reduced the amount of irradiated lung in all patients and reduced the amount of heart volume irradiated in 87% of left breast cancer patients. In-field organ volume is a valid surrogate for predicting dose; the trial continued to the planned target of 400.

Teaching and assessing systems-based practice: a pilot course in health care policy, finance, and law for radiation oncology residents.

BACKGROUND: Under the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, residency programs are required to provide data on educational outcomes and evidence for how this information is used to improve resident education. OBJECTIVE: To teach and assess systems-based practice through a course in health care policy, finance, and law for radiation oncology residents, and to determine its efficacy. METHODS AND MATERIALS: We designed a pilot course in health care policy, finance, and law related to radiation oncology. Invited experts gave lectures on policy issues important to radiation oncology and half of the participants attended the American Society for Therapeutic Radiation and Oncology (ASTRO) Advocacy Day. Participants completed pre- and postcourse tests to assess their knowledge of health policy. RESULTS: Six radiation oncology residents participated, with 5 (84%) completing all components. For the 5 residents completing all assessments, the mean precourse score was 64% and the mean postcourse score was 84% (P  =  .05). Improvement was noted in all 3 sections of health policy, finance, and medical law. At the end of the course, 5 of 6 residents were motivated to learn about health policy, and 4 of 6 agreed it was important for physicians to be involved in policy matters. CONCLUSIONS: Teaching radiation oncology residents systems-based practice through a course on health policy, finance, and law is feasible and was well received. Such a course can help teaching programs comply with the ACGME Outcome Project and would also be applicable to trainees in other specialties.

Decreasing temporal lobe dose with five-field intensity-modulated radiotherapy for treatment of pituitary macroadenomas.

PURPOSE: To compare temporal lobe dose delivered by three pituitary macroadenoma irradiation techniques: three-field three-dimensional conformal radiotherapy (3D-CRT), three-field intensity-modulated radiotherapy (3F IMRT), and a proposed novel alternative of five-field IMRT (5F IMRT). METHODS AND MATERIALS: Computed tomography-based external beam radiotherapy planning was performed for 15 pituitary macroadenoma patients treated at New York University between 2002 and 2007 using: 3D-CRT (two lateral, one midline superior anterior oblique [SAO] beams), 3F IMRT (same beam angles), and 5F IMRT (same beam angles with additional right SAO and left SAO beams). Prescription dose was 45 Gy. Target volumes were: gross tumor volume (GTV) = macroadenoma, clinical target volume (CTV) = GTV, and planning target volume = CTV + 0.5 cm. Structure contouring was performed by two radiation oncologists guided by an expert neuroradiologist. RESULTS: Five-field IMRT yielded significantly decreased temporal lobe dose delivery compared with 3D-CRT and 3F IMRT. Temporal lobe sparing with 5F IMRT was most pronounced at intermediate doses: mean V25Gy (% of total temporal lobe volume receiving ≥25 Gy) of 13% vs. 28% vs. 29% for right temporal lobe and 14% vs. 29% vs. 30% for left temporal lobe for 5F IMRT, 3D-CRT, and 3F IMRT, respectively (p < 10(-7) for 5F IMRT vs. 3D-CRT and 5F IMRT vs. 3F IMRT). Five-field IMRT plans did not compromise target coverage, exceed normal tissue dose constraints, or increase estimated brain integral dose. CONCLUSIONS: Five-field IMRT irradiation technique results in a statistically significant decrease in the dose to the temporal lobes and may thus help prevent neurocognitive sequelae in irradiated pituitary macroadenoma patients.

Quantitative assessment of radiation-induced fibrosis of the breast with tissue compliance meter, palpation, and radiological imaging: preliminary results.

Quantification of radiation (RT)-induced fibrosis (RIF) continues to present a challenge in breast cancer survivors. We compare assessment of RIF by palpation and tissue compliance meter (TCM) to the radiological findings in women treated with RT. Of 300 patients treated with adjuvant RT, 17 women had > or =2-year follow-up sufficient to document RIF. Palpation and TCM were employed by three radiation oncologists in a blinded fashion. Palpation grades 1, 2, and 3 denoted mild, moderate, and severe RIF. TCM measured degree of compliance (DC) of RIF in irradiated (RTB) and nonirradiated breasts (NRTB). Architectural distortions (AD) on mammograms, ultrasound (US), and MRI were assessed. Median time of follow up was 3.9 years (range 2.1-6.5 years). Palpation revealed RIF grades 1, 2, and 3 in four, 10, and three patients, respectively. Mean percent changes (PC) in DC between RTB and NRTB by TCM were 19.5%, 37.1%, and 57.5% for grades 1, 2, and 3 RIF, respectively (p < 0.0001). There was a strong linear correlation between palpation grade and PC of DC by TCM (spearman-rank correlation=0.88, p < 0.0001). Interobserver variability (reliability) was computed using intraclass correlation coefficient (ICC) for TCM and kappa statistic for clinical palpation (ICC=0.99 [p < 0.0001] and kappa=0.70 [p < 0.0001], respectively). There was no correlation between average size of the AD as measured by the imaging modalities and RIF as assessed by palpation or TCM. Our preliminary data suggest that quantification of RIF is best with TCM. TCM results correlate better with palpation than with radiological imaging. The study with larger number of patients required to confirm our findings is underway.

Feasibility of accelerated whole-breast radiation in the treatment of patients with ductal carcinoma in situ of the breast.

BACKGROUND: We report the results of a prospective trial investigating the use of accelerated, hypofractionated whole-breast radiation therapy after breast-conservation surgery for ductal carcinoma in situ (DCIS). PATIENTS AND METHODS: A total of 59 patients with a median age of 54 years (range, 36-78 years) completed a phase I/II study of hypofractionated radiation therapy for treatment of DCIS. Eligibility criteria included patients with mammographically detected DCIS, status after segmental mastectomy with negative margins, and no residual calcifications. All patients were treated with external-beam radiation therapy without a boost, over 3 weeks, to a total dose of 42 Gy to the entire breast (2.8 Gy per fraction in 15 fractions). To optimally spare heart and lung, 34 of the 59 patients (57%) were treated in the prone position. Twenty-nine of 59 patients (49%) received adjuvant hormonal therapy. RESULTS: Overall, radiation therapy was well tolerated, with modest acute toxicity limited to grade 1 radiation dermatitis (76%), breast edema (17%), and fatigue (12%). With a median follow-up of 36 months, late toxicities included grade 1 hyperpigmentation changes (85%), induration (66%), asymmetry (64%), and breast fibrosis (17%), with 3 cases of grade 2 fibrosis and 1 case of grade 2 hyperpigmentation. Among the patients with >or= 3 years of follow-up, cosmesis was scored as good to excellent in 21 patients (91%) and fair in 2 patients (9%). At the time of this report, no ipsilateral or contralateral breast recurrences have occurred. CONCLUSION: These data demonstrate the feasibility of treating the whole breast for DCIS with a hypofractionated regimen, with modest acute and late toxicity.

Possible association of p53 codon 72 polymorphism with susceptibility to adult and pediatric high-grade astrocytomas.

Polymorphisms in codon 72 of the p53 tumor suppressor gene have been associated with susceptibility to human cancer. We wished to evaluate whether variant allelic forms of the p53 protein were associated with brain tumors. In this study, we scored 135 brain tumor samples (92 adult and 43 pediatric cases consisting of 64 high-grade astrocytomas and 71 non-astrocytomas) for the P53 Arg72Pro polymorphisms. Our data show that the genotype frequencies of P53 Arg72Pro vary not only between patients with brain tumors and controls, but also between different histological subtypes of brain tumors. Specifically, we found (i) that the genotype distributions of the P53 Arg72Pro between all brain tumors and controls were statistically significant (P < 0.001) as well as their variant allele frequencies between cases and controls (P < 0.001); (ii) that there was a significant increase in the Arg/Pro heterozygous genotype among high-grade astrocytomas compared with non-astrocytomas (P = 0.002); and (iii) that there was a significant increase in the Arg/Pro heterozygous genotype among high-grade astrocytomas containing transdominant as well as recessive p53 mutations compared with controls (P = 0.002). Our results suggest a possible association between P53 Arg72Pro polymorphisms and susceptibility to brain tumors, particularly high-grade astrocytomas.

Pharmacogenomics and breast cancer.

Germline variants can be used to study breast cancer susceptibility as well as the variable response to both drug and radiation therapy used in the treatment of breast cancer. In addition to germline high-penetrance mutations important in familial and hereditary breast cancer, a substantial component of breast cancer risk can be attributed to the combined effect of many low-risk germline polymorphisms involved in relevant pathways like those of DNA repair, adhesion, carcinogen and estrogen metabolism. Additionally, the identification of sequence variants in genes involved in response to chemotherapy and radiation treatment, has created the opportunity to apply genomics to individualized treatment. The continued insight into the molecular pathways involved in drug and radiation response has enabled progress in tailoring therapies in such a way as to both maximize efficacy and minimize toxicity. Polymorphisms in genes encoding drug-metabolizing enzymes, drug transporters and drug targets can be used to predict toxicity and response to pharmacologic agents used in breast cancer treatment. Similarly, germline variants in genes involved in DNA repair, radiation-induced fibrosis and reactive oxygen species may be used to predict response to radiation therapy. As a result, pharmacogenomics is rapidly evolving to affect the entire spectrum of breast cancer management, influencing both prevention and treatment choices.