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1.
Br J Radiol ; 93(1108): 20190792, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31939310

RESUMO

OBJECTIVES: To evaluate the feasibility and optimal restricted angle of the complete-directional-complete block (CDCB) technique in helical tomotherapy (HT) by including regional nodal irradiation (RNI) with the internal mammary node (IMN) in left-sided breast cancer. METHODS: Ten left-sided breast cancer patients treated with 50 Gy in 25 fractions were compared with five-field intensity-modulated radiation therapy (5F-IMRT) and six types of HT plans. In the HT plans, complete block (CB), organ-based directional block (OBDB) and CDCB with different restricted angles were used. RESULTS: The conformity index (CI) between the CDCB0,10,15,20 and 5F-IMRT groups was similar. Compared to CB, OBDB and 5F-IMRT, CDCB20 resulted in a decreased ipsilateral mean lung dose. The low-dose region (V5) of the ipsilateral lung in OBDB (84.0%) was the highest among all techniques (p < 0.001). The mean dose of the heart in CB was significantly reduced (by 11.5-22.4%) compared with other techniques. The V30 of the heart in CDCB20 (1.9%) was significantly lower than that of CB, OBDB and 5F-IMRT. Compared to the mean dose of the left anterior descending (LAD) artery of 5F-IMRT (27.0 Gy), CDCB0, CDCB10, CDCB15, CDCB20 and OBDB reduced the mean dose effectively by 31.7%, 38.3%, 39.6%, 42.0 and 56.2%, respectively. Considering the parameters of the organs-at-risk (OARs), CDCB10,15,20 had higher expectative values than the other techniques (p = 0.01). CONCLUSIONS: HT with the CDCB technique is feasible for treating left-sided breast cancer patients. The CDCB10-20 techniques not only achieved similar planning target volume coverage, homogeneity and dose conformity but also allowed better sparing of the heart and bilateral lungs. ADVANCES IN KNOWLEDGE: For left-sided breast cancer patients whose RNI field includes the IMN, heart avoidance is an important issue. The CDCB technique achieved good PTV coverage, homogeneity and dose conformity and allowed better sparing of the mean dose of the lung, the LAD artery, and the heart and reduced the V30 of the heart.


Assuntos
Coração/efeitos da radiação , Pulmão/efeitos da radiação , Irradiação Linfática/métodos , Órgãos em Risco/efeitos da radiação , Lesões por Radiação/prevenção & controle , Radioterapia de Intensidade Modulada/métodos , Neoplasias Unilaterais da Mama/radioterapia , Fracionamento da Dose de Radiação , Estudos de Viabilidade , Feminino , Humanos , Órgãos em Risco/diagnóstico por imagem , Planejamento da Radioterapia Assistida por Computador/métodos , Neoplasias Unilaterais da Mama/diagnóstico por imagem
2.
Medicine (Baltimore) ; 98(39): e17340, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31574873

RESUMO

Radiotherapy after breast-conserving surgery or mastectomy has clinical benefits including reducing local recurrence and improving overall survival. Deep inspiration breath-hold (DIBH) technique using the Abches system is an easy and practical method to reduce radiation dose to the heart and lungs. This retrospective study was proposed to investigate the dosimetric difference between Abches system and free breathing technique in treating left-sided breast cancer.Eligible patients underwent computed tomography (CT) scans to acquire both free breathing (FB) and DIBH technique data using the Abches. For each patient, both FB and DIBH image sets were planned based on the volumetric modulated arc therapy (VMAT). Radiation dose to the heart, ipsilateral lung, and contralateral lung was compared between the Abches system and FB.No significant differences in the planning target volume (PTV) (674.58 vs 665.88 cm, P = .29), mean dose (52.28 vs 52.03 Gy, P = .13), and volume received at the prescribed dose (Vpd) (94.66% vs 93.92%, P = .32) of PTV were observed between the FB and DIBH plans. Significant differences were found in mean heart (6.71 Gy vs 4.21 Gy, P < .001), heart V5 (22.73% vs 14.39%, P = .002), heart V20 (10.96% vs. 5.62%, P < .001), mean left lung (11.51 vs 10.07 Gy, P = .01), left lung V20 (22.88% vs 19.53%, P = .02), left lung V30 (18.58 vs 15.27%, P = .005), and mean right lung dose (.89 vs 72 Gy, P = .03).This is the first report on reduced mean left lung, mean right lung dose, and V20 of left lung using VMAT and Abches. The combination of Abches and VMAT can practically and efficiently reduce extraradiation doses to the heart and lungs.


Assuntos
Radioterapia de Intensidade Modulada/métodos , Terapia Respiratória/métodos , Neoplasias Unilaterais da Mama/radioterapia , Adulto , Idoso , Suspensão da Respiração , Terapia Combinada , Feminino , Coração/efeitos da radiação , Humanos , Inalação , Pulmão/efeitos da radiação , Mastectomia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/prevenção & controle , Órgãos em Risco/efeitos da radiação , Dosagem Radioterapêutica , Estudos Retrospectivos , Resultado do Tratamento
3.
Radiat Oncol ; 14(1): 156, 2019 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-31477165

RESUMO

BACKGROUND: Adjuvant radiotherapy is the standard treatment after breast-conserving surgery. According to meta-analyses, adjuvant 3d-conventional irradiation reduces the risk of local recurrence and thereby improves long-term survival by 5-10%. However, there is an unintended exposure of organs such as the heart, lungs and contralateral breast. Irradiation of the left breast has been related to long-term effects like increased rates of coronary events as well as second cancer induction. Modern radiotherapy techniques such as tangential intensity modulated radiotherapy (t-IMRT) and tangential volumetric modulated arc therapy (t-VMAT) and particularly deep inspiration breath hold (DIBH) technique have been developed in order to improve coverage of target volume and to reduce dose to normal tissue. The aim of this study was to compare t-IMRT-plans with t-VMAT-plans in DIBH position for left-sided breast irradiation in terms of normal tissue exposure, i.e. of lungs, heart, left anterior descending coronary artery (LADCA), as well as homogeneity (HI) and conformity index (CI) and excess absolute risk (EAR) for second cancer induction for organs at risk (OAR) after irradiation. METHODS: Twenty patients, diagnosed with left-sided breast cancer and treated with breast-preserving surgery, were included in this planning study. For each patient DIBH-t-IMRT plan using 5 to 7 beams and t-VMAT plan using four rotations were generated to achieve 95% dose coverage to 95% of the volume. Data were evaluated on the basis of dose-volume histograms: Cardiac dose and LADCA (mean and maximum dose, D25% and D45%), dose to ipsilateral and contralateral lung (mean, D20%, D30%), dose to contralateral breast (mean dose), total monitor units, V5% of total body and normal tissue integral dose (NTID). In addition, homogeneity index and conformity index, as well as the excess absolute risk (EAR) to estimate the risk of second malignancy were calculated. RESULTS: T-IMRT showed a significant reduction in mean cardiac dose of 26% (p = 0.002) compared to t-VMAT, as well as a significant reduction in the mean dose to LADCA of 20% (p = 0.03). Following t-IMRT, mean dose to the left lung was increased by 5% (p = 0.006), whereas no significant difference was found in the mean dose to the right lung and contralateral breast between the two procedures. Monitor units were 31% (p = 0.000004) lower for t-IMRT than for t-VMAT. T-IMRT technique significantly reduced normal tissue integral dose (NTID) by 19% (p = 0.000005) and the V5% of total body by 24% (p = 0.0007). In contrast, t-VMAT improved CI and HI by 2% (p = 0.001) and 0.4% (p = 0.00001), respectively. EAR with t-IMRT was significantly lower, especially for contralateral lung and contralateral breast (2-5/10,000 person years) but not for ipsilateral lung. CONCLUSION: Compared to t-VMAT, t-IMRT in left-sided breast irradiation significantly reduced dose to organs at risk as well as normal tissue integral dose, and V5% total body. EAR with t-IMRT was significantly lower for contralateral lung and contralateral breast. T-VMAT, however, achieved better homogeneity and conformity. This may be relevant in individual cases where sufficient coverage of medial lymphatic target volumes is warranted.


Assuntos
Carcinoma Ductal de Mama/radioterapia , Carcinoma Intraductal não Infiltrante/radioterapia , Órgãos em Risco/efeitos da radiação , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia de Intensidade Modulada/métodos , Neoplasias Unilaterais da Mama/radioterapia , Adulto , Idoso , Carcinoma Ductal de Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , Feminino , Humanos , Pessoa de Meia-Idade , Invasividade Neoplásica , Prognóstico , Dosagem Radioterapêutica , Estudos Retrospectivos , Neoplasias Unilaterais da Mama/patologia
4.
Int J Radiat Oncol Biol Phys ; 105(3): 471-472, 2019 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-31540590
6.
Radiat Oncol ; 14(1): 153, 2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31462267

RESUMO

PURPOSE: The heart and lungs are routinely exposed to incidental irradiation during adjuvant radiotherapy (RT) of breast cancer. We analyzed the impact of patient and treatment characteristics on heart and lung dose in left-sided breast RT. METHODS: We analyzed 332 female patients treated with left-sided breast RT between 2013 and 2018. Mean heart dose (MHD), left mean lung dose (MLD) and heart / lung V20Gy were collected from treatment plans. Patients were stratified by RT technique (3D-conformal RT, 3DCRT; intensity-modulated RT, IMRT; volumetric modulated arc therapy, VMAT) and target volumes, including lymph node RT (LN-RT). Patient characteristics (body mass index (BMI), heart and lung volume) were assessed using correlation analyses. RESULTS: LN-RT was performed in 111 patients with increased MHD (median 4.6 vs. 3.3 Gy; p < .01), left MLD (14.8 vs. 7.7 Gy; p < .01) and left lung V20Gy (30.0% vs. 14.4%; p < .01) compared to treatment without LN-RT. Internal mammary LN-RT further increased organ doses compared to RT involving only supraclavicular +/- axillary LN (p < .01 for all values; MHD 6.9 vs. 4.2 Gy). In 221 patients treated without LN-RT, IMRT/VMAT was associated with higher left lung doses (MLD 9.1 vs. 7.4 Gy, p < .01; V20Gy 18.8% vs. 14.0%, p < .01) compared to 3DCRT. A negative correlation between total lung volume and both MHD (r = - 0.38; p < .01) and heart V20Gy (r = - 0.37; p < .01), as well as a weak positive correlation of BMI and MHD (r = 0.27; p < .01) were observed. CONCLUSIONS: In adjuvant RT for left-sided breast cancer, LN-RT is associated with a marked increase in heart and lung doses, particularly with internal mammary LN-RT. Potential advantages of IMRT/VMAT for breast or chest wall RT need to be weighed against a moderately increased lung dose.


Assuntos
Coração/efeitos da radiação , Pulmão/efeitos da radiação , Órgãos em Risco/efeitos da radiação , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia Adjuvante/métodos , Radioterapia Conformacional/métodos , Neoplasias Unilaterais da Mama/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Prognóstico , Dosagem Radioterapêutica , Estudos Retrospectivos , Neoplasias Unilaterais da Mama/patologia
7.
Acta Oncol ; 58(9): 1250-1258, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31219359

RESUMO

Background: In this study, we evaluate the evolution of cardiac changes during a three-year follow-up after adjuvant breast radiotherapy (RT). Methods: Sixty patients with left-sided and 20 patients with right-sided early stage breast cancer without chemotherapy were included in this prospective study. Echocardiography and cardiac biomarkers were evaluated before, immediately after and 3 years after RT. Radiation doses to cardiac structures were calculated. Results: In echocardiography, left ventricle (LV) systolic measurements had impaired at 3 years compared to baseline: the mean global longitudinal strain (GLS) worsened from -18 ± 3 to -17 ± 3 (p = .015), LV ejection fraction from 62 ± 5% to 60 ± 4% (p = .003) and the stroke volume from 73 ± 16 mL to 69 ± 15 mL (p = .015). LV diastolic function was also negatively affected: the isovolumetric relaxation time was prolonged (p = .006) and the first peak of diastole decreased (p = .022). Likewise, left atrial (LA) measurements impaired. These changes in echocardiography were more prominent in left-sided than in right-sided patients. The concurrent aromatase inhibitor (AI) use was associated with GLS impairment. In all patients, the N-terminal pro-brain natriuretic peptide (proBNP) values were median (interquartile range) 74 (41-125) ng/L at baseline, 75 (41-125) ng/L at the end of RT and 96 (56-162) ng/L at 3 years (p < .001 from baseline to 3 years). However, proBNP did not increase in right-sided patients. Conclusion: During the 3-year follow-up after RT, negative subclinical changes in cardiac biomarkers and in LV systolic and diastolic function were observed. The measured changes were more pronounced in left-sided patients. In addition, AI use was associated with impaired cardiac systolic function.


Assuntos
Carcinoma Intraductal não Infiltrante/radioterapia , Coração/efeitos da radiação , Neoplasias Unilaterais da Mama/radioterapia , Adulto , Idoso , Biomarcadores/análise , Carcinoma Intraductal não Infiltrante/patologia , Carcinoma Intraductal não Infiltrante/cirurgia , Ecocardiografia , Feminino , Seguimentos , Átrios do Coração/efeitos da radiação , Ventrículos do Coração/fisiopatologia , Ventrículos do Coração/efeitos da radiação , Humanos , Pessoa de Meia-Idade , Peptídeo Natriurético Encefálico/análise , Doses de Radiação , Radioterapia Adjuvante/efeitos adversos , Volume Sistólico/efeitos da radiação , Fatores de Tempo , Neoplasias Unilaterais da Mama/patologia , Neoplasias Unilaterais da Mama/cirurgia , Função Ventricular Esquerda/efeitos da radiação
8.
Radiat Oncol ; 14(1): 109, 2019 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-31215458

RESUMO

BACKGROUND: The aim of this study was to compare dose-volume histogram (DVH) with dose-mass histogram (DMH) parameters for treatment of left-sided breast cancer in deep inspiration breath-hold (DIBH) and free breathing (FB). Additionally, lung expansion and anatomical factors were analyzed and correlated to dose differences. METHODS: For 31 patients 3D conformal radiation therapy plans were retrospectively calculated on FB and DIBH CTs in the treatment planning system. The calculated doses, structures and CT data were transferred into MATLAB and DVHs and DMHs were calculated. Mean doses (Dmean), volumes and masses receiving certain doses (Vx, Mx) were determined for the left lung and the heart. Additionally, expansion of the left lung was evaluated using deformable image registration. Differences in DVH and DMH dose parameters between FB and DIBH were statistically analyzed and correlated to lung expansion and anatomical factors. RESULTS: DIBH reduced Dmean (DVH) and relative V20 (V20 [%]) of the left lung in all patients, on average by - 19 ± 9% (mean ± standard deviation) and - 24 ± 10%. Dmean (DMH) and M20 [%] were also significantly reduced (- 12 ± 11%, - 16 ± 13%), however 4 patients had higher DMH values in DIBH than in FB. Linear regression showed good correlations between DVH and DMH parameters, e.g. a dosimetric benefit smaller than 8.4% for Dmean (DVH) in DIBH indicated more irradiated lung mass in DIBH than in FB. The mean expansion of the left lung between FB and DIBH was 1.5 ± 2.4 mm (left), 16.0 ± 4.0 mm (anterior) and 12.2 ± 4.6 mm (caudal). No significant correlations were found between expansions and differences in Dmean for the left lung. The heart dose in DIBH was reduced in all patients by 53% (Dmean) and this dosimetric benefit correlated to lung expansion in anterior. CONCLUSIONS: Treatment of left-sided breast cancer in DIBH reduced dose to the heart and in most cases the lung dose, relative irradiated lung volume and lung mass. A mass related dosimetric benefit in DIBH can be achieved as long as the volume related benefit is about ≥8-9%. The lung expansion (breathing pattern) showed no impact on lung dose, but on heart dose. A stronger chest breathing (anterior expansion) for DIBH seems to be more beneficial than abdominal breathing.


Assuntos
Suspensão da Respiração , Pulmão/efeitos da radiação , Tratamentos com Preservação do Órgão/estatística & dados numéricos , Órgãos em Risco/efeitos da radiação , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Planejamento da Radioterapia Assistida por Computador/métodos , Neoplasias Unilaterais da Mama/radioterapia , Feminino , Coração/efeitos da radiação , Humanos , Processamento de Imagem Assistida por Computador/métodos , Prognóstico , Lesões por Radiação/prevenção & controle , Dosagem Radioterapêutica , Radioterapia Conformacional/métodos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Neoplasias Unilaterais da Mama/patologia
9.
Breast J ; 25(4): 682-686, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31077484

RESUMO

The purpose of this study was to analyze the effectiveness of electron beam therapy (EBT) with patient-tailored bolus (PTB) using three-dimensional printing technology to reduce heart and lung doses during post-mastectomy radiotherapy (PMRT). For 28 patients with left breast cancer, we designed customized virtual bolus for PMRT to compensate for surface irregularities on computed tomography images and developed optimized plans for EBT. As comparison between the PTB and tangential plans, the PTB plan reduced unnecessary exposure to heart and ipsilateral lung with better target coverage compared with the tangential technique.


Assuntos
Coração , Radioterapia/métodos , Neoplasias Unilaterais da Mama/radioterapia , Neoplasias Unilaterais da Mama/cirurgia , Adulto , Idoso , Feminino , Humanos , Pulmão , Mastectomia , Pessoa de Meia-Idade , Tratamentos com Preservação do Órgão , Impressão Tridimensional , Radiodermatite , Radioterapia/efeitos adversos , Dosagem Radioterapêutica , Tomografia Computadorizada por Raios X , Neoplasias Unilaterais da Mama/diagnóstico por imagem
10.
Int J Radiat Oncol Biol Phys ; 104(3): 488-493, 2019 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-30944071

RESUMO

PURPOSE: Interstate variations in Medicaid reimbursements can be significant, and patients who live in states with low Medicaid reimbursements tend to have worse access to care. This analysis describes the extent of variations in Medicaid reimbursements for radiation oncology services across the United States. METHODS AND MATERIALS: The Current Procedural Terminology codes billed for a course of whole breast radiation were identified for this study. Publicly available fee schedules were queried for all 50 states and Washington, DC, to determine the reimbursement for each service and the total reimbursement for the entire episode of care. The degree of interstate payment variation was quantified by computing the range, mean, standard deviation, and coefficient of variation. The cost of care for the entire episode of treatment was compared to the publicly available Kaiser Family Foundation (KFF) Medicaid-to-Medicare fee index to determine if the pattern of payment variation in medical services generally is predictive of the variation seen in radiation oncology specifically. RESULTS: Data were available for 48 states and Washington, DC. The total episode reimbursement (excluding image guidance for respiratory tracking) varied from $2945 to $15,218 (mean, $7233; standard deviation, $2248 or 31%). The correlation coefficient of the KFF index to the calculated entire episode of care for each state was 0.55. CONCLUSIONS: There is considerable variability in coverage and payments rates for radiation oncology services under Medicaid, and these variations track modestly with broader medical fees based on the KFF index. These variations may have implications for access to radiation oncology services that warrant further study.


Assuntos
Tabela de Remuneração de Serviços/economia , Medicaid/economia , Radioterapia (Especialidade)/economia , Mecanismo de Reembolso/economia , Neoplasias Unilaterais da Mama/economia , Codificação Clínica/economia , Cuidado Periódico , Feminino , Sistemas Pré-Pagos de Saúde/economia , Humanos , Movimentos dos Órgãos , Hipofracionamento da Dose de Radiação , Radioterapia Guiada por Imagem/economia , Mecanismo de Reembolso/normas , Respiração , Neoplasias Unilaterais da Mama/radioterapia , Estados Unidos
11.
Cancer Radiother ; 23(2): 92-97, 2019 Apr.
Artigo em Francês | MEDLINE | ID: mdl-30954386

RESUMO

PURPOSE: Adjuvant left-sided breast cancer locoregional radiotherapy can be accounted for long-term cardiac toxicity. The deep inspiration breath hold techniques can reduce cardiac doses. Only a few studies have investigated rotational intensity-modulated radiotherapy with deep inspiration breath hold. MATERIAL AND METHODS: We conducted a dosimetric study comparing rotational intensity-modulated radiotherapy in free breathing with deep inspiration breath hold for irradiation of left breast cancer and locoregional lymph nodes. Doses to organs at risk were compared, as well as doses to coronary arteries, left anterior descending coronary artery region, and aortic valve. RESULTS: The data from nine patients were included in the study. Treatment plans were comparable for target volumes. The deep inspiration breath hold delivery technique, compared with free breathing, reduced radiation dose to the heart (mean dose 4.8Gy vs. 6.6Gy, p=0.008; dose in 2% of the volume 16.8Gy vs. 23.3Gy, p=0.008; volume receiving 25Gy 0.8% vs. 2,2%, p=0.008; volume receiving 30Gy 0.4% vs. 1.2%, p=0.009), as well as to the right coronary artery (mean dose 6Gy vs. 8.9Gy, p=0.028), to the left anterior descending artery (mean dose 9.6Gy vs. 14.6Gy, p=0.021), to the left anterior descending coronary artery region (dose in 2% of the volume 17.4Gy vs. 24.6Gy, p=0.021), and to the aortic valve (mean dose 4.8Gy vs. 7Gy, p=0.028). Other doses to organs at risk were similar. CONCLUSION: Rotational intensity-modulated radiotherapy with deep inspiration breath hold is associated with better sparing of the heart, on the right and left anterior descending coronary arteries, and on the aortic valve, compared with free breathing techniques, for adjuvant left breast cancer locoregional irradiation.


Assuntos
Suspensão da Respiração , Coração/efeitos da radiação , Órgãos em Risco , Radioterapia de Intensidade Modulada/métodos , Neoplasias Unilaterais da Mama/radioterapia , Feminino , Humanos , Tratamentos com Preservação do Órgão , Dosagem Radioterapêutica , Radioterapia de Intensidade Modulada/efeitos adversos , Sistema de Registros
12.
Phys Med ; 59: 79-85, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30928069

RESUMO

PURPOSE: Volumetric modulated arc therapy (VMAT) for left breast treatments allows heart sparing without compromising PTV coverage. However, this technique may require highly complex plans. Deep Inspiration Breath Hold (DIBH) procedure increases the heart-to-breast distance, facilitating the dose sparing of the heart. The aim of the present work was to investigate if the cardiac-sparing benefits of the DIBH technique were achieved with lower plan modulation and complexity than Free Breathing (FB) treatments. METHODS AND MATERIALS: Ten left side breast cases were considered by two centers with different treatment planning systems (TPS) and Linacs. VMAT plans were elaborated in FB and DIBH according to the same protocol. Plan complexity was evaluated by scoring several complexity indices. A new global score index accounting for both plan quality and dosimetric parameters was defined. Pre-treatment QA was performed for all VMAT plans using EPID and Epiqa software. RESULTS: DIBH-VMAT plans were associated with significant PTV coverage improvement and mean heart dose reduction (p < 0.003), increasing the resulting global score index. All the evaluated complexity indices showed lower plan complexity for DIBH plans than FB ones, but only in few cases the results were statistically significant. All plans passed the gamma analysis with the selected criteria. CONCLUSIONS: The DIBH technique is superior to the FB technique when the heart needs further sparing, allowing a reduction of the doses to OARs with a slightly lower degree of plan complexity and without compromising plan deliverability. These benefits were achieved regardless of the technological scenarios adopted.


Assuntos
Suspensão da Respiração , Inalação , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia de Intensidade Modulada , Neoplasias Unilaterais da Mama/radioterapia , Estudos de Viabilidade , Humanos , Radiometria , Neoplasias Unilaterais da Mama/fisiopatologia
13.
Bull Cancer ; 106(4): 379-388, 2019 Apr.
Artigo em Francês | MEDLINE | ID: mdl-30905377

RESUMO

Adjuvant radiation therapy in breast cancer is a standard of care, either post-lumpectomy or in case of lymph node involvement. Internal mammary chain (IMC) is more and more included in the clinical target volume, because it increases overall survival. This increase must be weighed against cardiac complications in left breast cancer. Intensity modulated radiation therapy (IMRT) is used in this indication in order to better cover target volumes, but tends to increase irradiated healthy volumes, including the heart. The average cardiac dose is higher with IMRT, while it is also predictive of cardiovascular events in patients treated in 3D. This article aims to make an inventory of the IMC irradiations, as well as a review of the mechanisms of radiation-induced cardiac toxicity and ways to diagnose it early. Cooperation between medical oncologists, radiotherapy oncologists and cardiologists is needed to better support patients.


Assuntos
Cardiopatias/etiologia , Coração/efeitos da radiação , Órgãos em Risco/efeitos da radiação , Lesões por Radiação/complicações , Radioterapia de Intensidade Modulada/efeitos adversos , Neoplasias Unilaterais da Mama/radioterapia , Feminino , Cardiopatias/diagnóstico , Cardiopatias/prevenção & controle , Humanos , Lesões por Radiação/diagnóstico , Lesões por Radiação/prevenção & controle , Dosagem Radioterapêutica , Radioterapia Adjuvante/efeitos adversos , Radioterapia de Intensidade Modulada/métodos
14.
J Appl Clin Med Phys ; 20(2): 24-29, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30653831

RESUMO

Volumetric modulated arc therapy (VMAT) has been implemented for left breast irradiation to reduce prescription dose to the heart and improve dose homogeneity across the targeted breast. Our in-house method requires application of a bolus during the optimization process with a target outside of the body, then removing the bolus during the final calculation in order to incorporate skin flash in VMAT plans. To quantify the dosimetric trade-offs between traditional 3D field-in-field tangents and VMAT with integrated skin flash for these patients, we compared nine consecutive patients who recently received radiation to their entire left breast but not their regional lymphatics. Tangent plans used non-divergent tangents of mixed energies and VMAT plans utilized four 6 MV arcs of roughly 260°. Mean dose to the heart, contralateral lung, and contralateral breast and their volume receiving 5%, 10%, and 20% of the prescription dose were higher in all nine VMAT plans than in the static tangential beam plans. For all critical structures, the mean VMAT DVH was higher in the low-dose region and crossed the 3D field-in-field DVH between 23.13% and 34.18% of the prescription dose (984.75-1454.70 cGy). However, the volume of the contralateral breast and heart receiving the prescription dose was slightly lower in the VMAT plans, but not statistically significant. VMAT provided superior homogeneity, with a mean homogeneity index of 9.41 ± 1.64 compared to 11.05 ± 1.82 for 3D tangents. Results indicate that VMAT spares the heart, contralateral lung, and contralateral breast from prescription dose at the cost of increasing their mean and low-dose volume and delivers a more homogenous dose distribution to the breast. For these reasons, VMAT is selectively applied at the request of the physician for left breast radiation without respiratory gating to spare the heart from prescription dose in cases of poor anatomical geometry.


Assuntos
Imageamento Tridimensional/métodos , Órgãos em Risco/efeitos da radiação , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia de Intensidade Modulada/métodos , Pele/efeitos da radiação , Neoplasias Unilaterais da Mama/radioterapia , Feminino , Coração/efeitos da radiação , Humanos , Pulmão/efeitos da radiação , Prognóstico , Dosagem Radioterapêutica , Tomografia Computadorizada por Raios X/métodos , Neoplasias Unilaterais da Mama/diagnóstico por imagem
15.
Health Phys ; 116(5): 631-636, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30608247

RESUMO

This study aimed to compare and evaluated the dosimetric characteristics of esophagus, spinal cord, carotid artery, lungs, and brachial plexus in patients with breast cancer undergoing four various techniques of supraclavicular irradiation. By keeping unchanged the breast tangential radiotherapy fields, four different treatment field arrangements were created to irradiate the supraclavicular region as follows: (1) four field (4F; 1 anterior-posterior and 1 posterior-anterior), (2) six field (6F; 2 anterior-posterior and 2 posterior-anterior), (3) five field-1 (5F-1; 2 anterior-posterior and 1 posterior-anterior), and (4) five field-2 (5F-2; 1 anterior-posterior and 2 posterior-anterior). Then, the dosimetric parameters for the above-mentioned organs were evaluated. The mean dose (Dmean) of the esophagus had significant difference between 6F and 5F-2 techniques. For the spinal cord, the Dmean dosimetric parameter demonstrated significant difference between the 4F and 6F techniques, and between the 4F and 5F-1 techniques, with lower values for the 4F technique. There was no significant difference between the different irradiation techniques in all the dosimetric parameters for the carotid artery. The Dmean of the left lung significantly differed between the 4F and 5F-2 techniques, with lower values for the 5F-2 technique. Furthermore, the V20Gy dosimetric parameter had significant difference between the 4F and 6F, and also 4F and 5F-2, techniques with lower values for 5F-2. The maximum dose (Dmax) of the brachial plexus showed significant difference between the two techniques of 5F. The V45Gy dosimetric parameter of the brachial plexus revealed significant difference between the 4F and 6F techniques, and also between the 4F and 5F-1 techniques, with lower values for 5F-1. In general, these techniques had similar dosimetric results, with little differences. The dosimetric parameters for the esophagus and lung showed better results with the 5F-2 technique in comparison with other techniques. Dosimetric results for the brachial plexus and spinal cord improved with the 5F-1 and 4F techniques, respectively, against other techniques. Dose distribution for the carotid artery did not differ in the four irradiation techniques.


Assuntos
Órgãos em Risco/efeitos da radiação , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia Conformacional/métodos , Neoplasias Unilaterais da Mama/radioterapia , Feminino , Coração/efeitos da radiação , Humanos , Pulmão/efeitos da radiação , Pessoa de Meia-Idade , Radiometria , Dosagem Radioterapêutica
16.
Radiother Oncol ; 131: 202-207, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30097250

RESUMO

PURPOSE: Aim of the current comparative modelling study was to estimate the individual radiation-induced risk for death of ischaemic heart disease (IHD) under free breathing (FB) and deep inspiration breath-hold (DIBH) in a real-world population. MATERIALS AND METHODS: Eighty-nine patients with left-sided early breast cancer were enrolled in the prospective SAVE-HEART study. For each patient three-dimensional conformal treatment plans were created in FB and DIBH and corresponding radiation-induced risks of IHD mortality were estimated based on expected survival, individual IHD risk factors and the relative radiation-induced risk. RESULTS: With the use of DIBH, mean heart doses were reduced by 35% (interquartile range: 23-46%) as compared to FB. Mean expected years of life lost (YLL) due to radiation-induced IHD mortality were 0.11 years in FB, and 0.07 years in DIBH. YLL were remarkably independent of age at treatment in patients with a favourable tumour prognosis. DIBH led to more pronounced reductions in YLL in patients with high baseline risk (0.08 years for upper vs 0.02 years for lower quartile), with favourable tumour prognosis (0.05 years for patients without vs 0.02 years for those with lymph-node involvement), and in patients with high mean heart doses in FB (0.09 years for doses >3 Gy vs 0.02 years for doses <1.5 Gy). CONCLUSION: Ideally, the DIBH technique should be offered to all patients with left-sided breast cancer. However, highest benefits are expected for patients with a favourable tumour prognosis, high mean heart dose or high baseline IHD risk, independent of their age.


Assuntos
Suspensão da Respiração , Coração/efeitos da radiação , Isquemia Miocárdica/etiologia , Lesões por Radiação/etiologia , Planejamento da Radioterapia Assistida por Computador/métodos , Neoplasias Unilaterais da Mama/radioterapia , Adulto , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Modelos Estatísticos , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/prevenção & controle , Estudos Prospectivos , Lesões por Radiação/epidemiologia , Lesões por Radiação/prevenção & controle , Dosagem Radioterapêutica , Radioterapia Conformacional/métodos , Radioterapia de Intensidade Modulada/métodos , Risco
17.
Strahlenther Onkol ; 195(1): 1-12, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30310926

RESUMO

BACKGROUND: Late cardiac toxicities caused by (particularly left-sided) breast radiotherapy (RT) are now recognized as rare but relevant sequelae, which has prompted research on risk structure identification and definition of threshold doses to heart subvolumes. The aim of the present review was to critically discuss the clinical evidence on late cardiac reactions based on dose-dependent outcome reports for mean heart doses as well as doses to cardiac substructures. METHODS: A literature review was performed to examine clinical evidence on radiation-induced heart toxicities. Mean heart doses and doses to cardiac substructures were focused upon based on dose-dependent outcome reports. Furthermore, an overview of radiation techniques for heart protection is given and non-radiotherapeutic aspects of cardiotoxicity in the multimodal setting of breast cancer treatment are discussed. RESULTS: Based on available findings, the DEGRO breast cancer expert panel recommends the following constraints: mean heart dose <2.5 Gy; DmeanLV (mean dose left ventricle) < 3 Gy; V5LV (volume of LV receiving ≥5 Gy) < 17%; V23LV (volume of LV receiving ≥23 Gy) < 5%; DmeanLAD (mean dose left descending artery) < 10 Gy; V30LAD (volume of LAD receiving ≥30 Gy) < 2%; V40LAD (volume of LAD receiving ≥40 Gy) < 1%. CONCLUSION: In addition to mean heart dose, breast cancer RT treatment planning should also include constraints for cardiac subvolumes such as LV and LAD. The given constraints serve as a clinicians' aid for ensuring adequate heart protection. The individual decision between sufficient protection of cardiac structures versus optimal target volume coverage remains in the physician's hand. The risk of breast cancer-specific mortality and a patient's cardiac risk factors must be individually weighed up against the risk of radiation-induced cardiotoxicity.


Assuntos
Coração/efeitos da radiação , Lesões por Radiação/diagnóstico , Neoplasias Unilaterais da Mama/radioterapia , Vasos Coronários/efeitos da radiação , Feminino , Ventrículos do Coração/efeitos da radiação , Humanos , Lesões por Radiação/etiologia , Lesões por Radiação/prevenção & controle , Dosagem Radioterapêutica , Fatores de Risco
18.
Brachytherapy ; 18(1): 50-56, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30262411

RESUMO

PURPOSE: Studies have shown that an additional mean dose of 1 Gy to the heart can increase the relative risk of cardiac events. The purpose of this study was to quantify the dose delivered to the heart and left anterior descending artery (LAD) in a series of patients with left-sided breast cancer (BC) or ductal carcinoma in situ treated with multicatheter-accelerated partial breast irradiation (MC-APBI) at a single institution. METHODS AND MATERIALS: Patients with left-sided BC or ductal carcinoma in situ treated consecutively from 2005 to 2011 with MC-APBI were retrospectively identified. Cardiac and LAD contours were generated for each patient. Cardiac dosimetry and distance to the planning target volume were recorded. Patient health records were reviewed and cardiac events were recorded based on Common Terminology Criteria for Adverse Events version 4.0. RESULTS: Twenty consecutive patients with left-sided BC treated with MC-APBI were retrospectively identified. Median followup was 41.4 months. Mean equivalent dose in 2 Gy fractions delivered to the heart and LAD were 1.3 (standard deviation: 0.7, range: 0.2-2.9) and 3.8 (standard deviation: 3.0, range: 0.4-11.3) Gy, respectively. There was an inverse linear relationship (R2 = 0.52) between heart-to-lumpectomy cavity distance and mean heart equivalent dose in 2 Gy fractions. One patient (5%) experienced symptomatic cardiac toxicity. CONCLUSIONS: MC-APBI consistently delivers average doses to the heart and LAD that are similar to those achieved in most series with deep inspiration breath-hold and lower than free-breathing radiotherapy techniques. Distance from the heart to the lumpectomy cavity and the availability of other heart-sparing technologies should be considered to minimize the risk of cardiac toxicity.


Assuntos
Braquiterapia/métodos , Neoplasias da Mama/radioterapia , Carcinoma Intraductal não Infiltrante/radioterapia , Vasos Coronários/efeitos da radiação , Coração/efeitos da radiação , Neoplasias Unilaterais da Mama/radioterapia , Idoso , Suspensão da Respiração , Cateterismo , Feminino , Humanos , Mastectomia Segmentar , Pessoa de Meia-Idade , Radiometria , Dosagem Radioterapêutica , Planejamento da Radioterapia Assistida por Computador , Estudos Retrospectivos
19.
Med Dosim ; 44(3): 210-218, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30166077

RESUMO

The aim of this study is to determine if RapidPlan (RP) can be used as a prediction method to determine which left-sided supine breast cancer patients would benefit from the deep inspiration breath-hold (DIBH) technique. An RP model database was created with 72 clinically approved 3D conformal radiation therapy (3D-CRT) treatment plans. This model was validated by introducing 10 new patient data sets, creating RP-generated plans and comparing the clinically approved plan for the corresponding patient. The prediction ability of the model was then tested on the free-breathing (FB) scans of patients with clinically approved DIBH plans totaling 29 patients and results were then compared to the FB clinical plan attempts. A statistical analysis performed on the data indicated a strong correlation for the mean heart dose (R2 = 0.914; p-value < 0.001) with a standard deviation of 48.6 cGy. After validating the link between physician PTV and mean heart dose, the model was tested clinically on 15 patients by inserting "Test PTV Evals" that were contoured by the researchers as a surrogate for predicting mean heart dose. Statistical analysis showed a strong correlation between the dose to 5% of the heart (D5) and the mean heart dose (R2 values of 0.913 and 0.881, respectively) with a standard deviation for the mean heart dose of 27.2 cGy. It was concluded that by using a Test PTV Eval, the RP-generated plans were able to predict mean heart doses within ± 30.0 cGy.


Assuntos
Suspensão da Respiração , Planejamento da Radioterapia Assistida por Computador/métodos , Radioterapia Conformacional/métodos , Neoplasias Unilaterais da Mama/radioterapia , Feminino , Humanos , Dosagem Radioterapêutica
20.
Strahlenther Onkol ; 195(1): 43-51, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30406290

RESUMO

BACKGROUND AND PURPOSE: In our institute, breast cancer patients undergoing adjuvant treatment are included in a protocol aimed to reduce cardiovascular morbidity (SAFE-2014, NCT2236806), assessing preclinical heart damage with heart speckle-tracking ultrasound. To develop a dose constraint related to subclinical heart damage, a reliable delineation of heart substructures based on a pre-existing guideline was made. PATIENTS AND METHODS: Heart substructures of 16 left-sided breast cancer patients included in the SAFE protocol were delineated by five operators. For each substructure, a multi-contour delineation based on a majority vote algorithm (MCD) was created. A consensus-based delineation (CBD) was developed by an independent team of two blinded operators. Dice similarity coefficients (DSC) between volumes delineated by different operators and the MCD were collected and reported, as well as DSC between CBD and MCD. RESULTS: Mean DSCs between heart chambers delineated by each operator and the corresponding MCDs ranged between 0.78 and 0.96. Mean DSC between substructures delineated by all single operators and the corresponding MCD ranged between 0.84 and 0.94. Mean DSC between CBD and the corresponding MCD ranged from 0.89 to 0.97. CONCLUSION: Results showed low inter-observer variability of heart substructure delineation. This constitutes an external validation of the contouring atlas used, allowing a reliable dosimetric assessment of these volumes within the SAFE-2014 trial.


Assuntos
Bisoprolol/administração & dosagem , Fidelidade a Diretrizes , Coração , Lesões por Radiação/prevenção & controle , Radioterapia Adjuvante/métodos , Ramipril/administração & dosagem , Neoplasias Unilaterais da Mama/radioterapia , Algoritmos , Cardiotônicos/administração & dosagem , Quimioterapia Adjuvante/métodos , Terapia Combinada/métodos , Quimioterapia Combinada , Ecocardiografia Doppler/métodos , Feminino , Coração/efeitos dos fármacos , Coração/efeitos da radiação , Humanos , Variações Dependentes do Observador , Garantia da Qualidade dos Cuidados de Saúde , Lesões por Radiação/diagnóstico por imagem , Radiometria/métodos , Reprodutibilidade dos Testes , Neoplasias Unilaterais da Mama/tratamento farmacológico
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