Intraoperative radiotherapy (IORT) of early breast cancer with low-energy x-rays in breast-conserving surgery : Prospective identification of pre- and intraoperative factors influencing the feasibility of IORT.

PURPOSE: The aim of this study is to identify pre- and intraoperative factors indicating the feasibility of intraoperative radiotherapy (IORT) during breast-conserving surgery (BCS). MATERIALS AND METHODS: From January 2018 to December 2019, a total of 128 women undergoing BCS due to early breast cancer were included in this prospective observational study, independent of whether IORT was planned or not. Patient and tumor characteristics as well as surgical parameters that could potentially influence the feasibility of IORT were recorded for the entire collective. In addition, a preoperative senological assessment was performed and analyzed to assess the feasibility of IORT. Logistic regression was then used to identify relevant preoperative parameters and to generate a formula predicting the feasibility of IORT. RESULTS: Of the 128 included women undergoing BCS, 46 were preoperatively rated to be feasible, 20 to be questionably feasible for IORT. Ultimately, IORT was realized in 30 patients. The most frequent reasons for omission of IORT were insufficient tumor-to-skin distance and/or an excessively large tumor cavity. Small clinical tumor size and large tumor-to-skin distance according to preoperative ultrasound were significantly related to accomplishment of IORT. CONCLUSION: We observed that preoperative ultrasound-based tumor-skin distance is a significant factor in addition to already known parameters to predict feasibility of IORT. Based on our findings we developed a formula to optimize IORT planning which might serve as an additional tool to improve patient selection for IORT in early breast cancer.

Low doses to the heart in daily practice for treating left-sided breast cancer using accelerated partial-breast irradiation by multicatheter brachytherapy and deep-inspiration breath-hold using a SIB.

PURPOSE: The aim of this study was to analyze the heart dose for left-sided breast cancer that can be achieved during daily practice in patients treated with multicatheter brachytherapy (MCBT) accelerated partial-breast irradiation (APBI) and deep-inspiration breath-hold (DIBH) whole-breast irradiation (WBI) using a simultaneous integrated tumor bed boost (SIB)-two different concepts which nonetheless share some patient overlap. MATERIALS AND METHODS: We analyzed the nominal average dose (Dmean) to the heart as well as the biologically effective dose (BED) and the equivalent dose in 2­Gy fractions (EQD2) for an α/ß of 3 in 30 MCBT-APBI patients and 22 patients treated with DIBH plus SIB. For further dosimetric comparison, we contoured the breast planning target volume (PTV) in each of the brachytherapy planning CTs according to the ESTRO guidelines and computed tangential field plans. Mean dose (Dmean), EQD2 Dmean, and BED Dmean for three dosing schemes were calculated: 50 Gy/25 fractions and two hypofractionated regimens, i.e., 40.05 Gy/15 fractions and 26 Gy/5 fractions. Furthermore, we calculated tangential field plans without a boost for the 22 cases treated with SIB with the standard dosing scheme of 40.05 Gy/15 fractions. RESULTS: MCBT and DIBH radiation therapy both show low-dose exposure of the heart. As expected, hypofractionation leads to sparing of the heart dose. Although MCBT plans were not optimized regarding dose to the heart, Dmean differed significantly between MCBT and DIBH (1.28 Gy vs. 1.91 Gy, p < 0.001) in favor of MCBT, even if the Dmean in each group was very low. In MCBT radiation, the PTV-heart distance is significantly associated with the dose to the heart (p < 0.001), but it is not in DIBH radiotherapy using SIB. CONCLUSION: In daily practice, both DIBH radiation therapy as well as MCBT show a very low heart exposure and may thus reduce long term cardiac morbidity as compared to currently available long-term clinical data of patients treated with conventional tangential field plans in free breathing. Our analysis confirms particularly good cardiac sparing with MCBT-APBI, so that this technique should be offered to patients with left-sided breast cancer if the tumor-associated eligibility criteria are fulfilled.

Benchmarking halcyon ring delivery system for hypofractionated breast radiotherapy: Validation and clinical implementation of the fast-forward trial.

PURPOSE: The aim of this study was to demonstrate the feasibility and efficacy of an iterative CBCT-guided breast radiotherapy with Fast-Forward trial of 26 Gy in five fractions on a Halcyon Linac. This study quantifies Halcyon plan quality, treatment delivery accuracy and efficacy by comparison with those of clinical TrueBeam plans. MATERIALS AND METHODS: Ten accelerated partial breast irradiation (APBI) patients (four right, six left) who underwent Fast-Forward trial at our institute on TrueBeam (6MV beam) were re-planned on Halcyon (6MV-FFF). Three site-specific partial coplanar VMAT arcs and an Acuros-based dose engine were used. For benchmarking, PTV coverage, organs-at-risk (OAR) doses, beam-on time, and quality assurance (QA) results were compared for both plans. RESULTS: The average PTV was 806 cc. Compared to TrueBeam plans, Halcyon provided highly conformal and homogeneous plans with similar mean PTVD95 (25.72  vs. 25.73 Gy), both global maximum hotspot < 110% (p = 0.954) and similar mean GTV dose (27.04  vs. 26.80 Gy, p = 0.093). Halcyon provided lower volume of ipsilateral lung receiving 8 Gy (6.34% vs. 8.18%, p = 0.021), similar heart V1.5 Gy (16.75% vs. 16.92%, p = 0.872), V7Gy (0% vs. 0%), mean heart dose (0.96  vs. 0.9 Gy, p = 0.228), lower maximum dose to contralateral breast (3.2  vs. 3.6 Gy, p = 0.174), and nipple (19.6  vs. 20.1 Gy, p = 0.363). Compared to TrueBeam, Halcyon plans provided similar patient-specific QA pass rates and independent in-house Monte Carlo second check results of 99.6% vs. 97.9% (3%/2 mm gamma criteria) and 98.6% versus 99.2%, respectively, suggesting similar treatment delivery accuracy. Halcyon provided shorter beam-on time (1.49  vs. 1.68 min, p = 0.036). CONCLUSION: Compared to the SBRT-dedicated TrueBeam, Halcyon VMAT plans provided similar plan quality and treatment delivery accuracy, yet potentially faster treatment via one-step patient setup and verification with no patient collision issues. Rapid delivery of daily APBI on Fast-Forward trial on Halcyon with door-to-door patient time < 10 min, could reduce intrafraction motion errors, and improve patient comfort and compliance. We have started treating APBI on Halcyon. Clinical follow-up results are warranted. We recommend Halcyon users consider implementing the protocol to remote and underserved APBI patients in Halcyon-only clinics.

A narrative review for radiation oncologists to implement preoperative partial breast irradiation.

The strategy to anticipate radiotherapy (RT) before surgery, for breast cancer (BC) treatment, has recently generated a renewed interest. Historically, preoperative RT has remained confined either to highly selected patients, in the context of personalized therapy, or to clinical research protocols. Nevertheless, in the recent years, thanks to technological advances and increased tumor biology understanding, RT has undergone great changes that have also impacted the preoperative settings, embracing the modern approach to breast cancer. In particular, the reappraisal of preoperative RT can be viewed within the broader view of personalized and tailored medicine. In fact, preoperative accelerated partial breast irradiation (APBI) allows a more precise target delineation, with less variability in contouring among radiation oncologists, and a smaller treatment volume, possibly leading to lower toxicity and to dose escalation programs. The aim of the present review, which represents a benchmark study for the AIRC IG-23118, is to report available data on different technical aspects of preoperative RT including dosimetric studies, patient's selection and set-up, constraints, target delineation and clinical results. These data, along with the ones that will become available from ongoing studies, may inform the design of the future trials and representing a step toward a tailored APBI approach with the potential to challenge the current treatment paradigm in early-stage BC.Trial registration: The study is registered at clinicaltrials.gov (NCT04679454).

Intraoperative electron radiotherapy in early invasive ductal breast cancer: 6-year median follow-up results of a prospective monocentric registry.

BACKGROUND: Intraoperative electron radiotherapy (IOERT) can be used to treat early breast cancer during the conservative surgery thus enabling shorter overall treatment times and reduced irradiation of organs at risk. We report on our first 996 patients enrolled prospectively in a registry trial. METHODS: At Jules Bordet Institute, from February 2010 onwards, patients underwent partial IOERT of the breast. Women with unifocal invasive ductal carcinoma, aged 40 years or older, with a clinical tumour size ≤ 20 mm and tumour-free sentinel lymph node (on frozen section and immunohistochemical analysis). A 21 Gy dose was prescribed on the 90% isodose line in the tumour bed with the energy of 6 to 12 MeV (Mobetron®-IntraOp Medical). RESULTS: Thirty-seven ipsilateral tumour relapses occurred. Sixteen of those were in the same breast quadrant. Sixty patients died, and among those, 12 deaths were due to breast cancer. With 71.9 months of median follow-up, the 5-year Kaplan-Meier estimate of local recurrence was 2.7%. CONCLUSIONS: The rate of breast cancer local recurrence after IOERT is low and comparable to published results for IORT and APBI. IOERT is highly operator-dependent, and appropriate applicator sizing according to tumour size is critical. When used in a selected patient population, IOERT achieves a good balance between tumour control and late radiotherapy-mediated toxicity morbidity and mortality thanks to insignificant irradiation of organs at risk.

CyberKnife versus multicatheter interstitial brachytherapy for accelerated partial breast irradiation: a dosimetrical assessment with focus on organs at risk.

Background: The purpose of the study was to dosimetrically compare multicatheter interstitial brachytherapy (MIBT) and stereotactic radiotherapy with CyberKnife (CK) for accelerated partial breast irradiation with special focus on dose to organs at risk (OARs). Materials and methods: Treatment plans of thirty-one patients treated with MIBT were selected and additional CK plans were created on the same CT images. The OARs included ipsilateral non-target and contralateral breast, ipsilateral and contralateral lung, skin, ribs, and heart for left sided cases. The fractionation was identical (4 × 6.25 Gy). Dose-volume parameters were calculated for both techniques and compared. Results: The D90 of the PTV for MIBT and CK were similar (102.4% vs. 103.6%, p = 0.0654), but in COIN the MIBT achieved lower value (0.75 vs. 0.91, p < 0.001). Regarding the V100 parameter of non-target breast CK performed slightly better than MIBT (V100: 1.1% vs. 1.6%), but for V90, V50 and V25 MIBT resulted in less dose. Every examined parameter of ipsilateral lung, skin, ribs and contralateral lung was significantly smaller for MIBT than for CK. Protection of the heart was slightly better with MIBT, but only the difference of D2cm3 was statistically significant (17.3% vs. 20.4%, p = 0.0311). There were no significant differences among the dose-volume parameters of the contralateral breast. Conclusion: The target volume can be properly irradiated by both techniques with high conformity and similar dose to the OARs. MIBT provides more advantageous plans than CK, except for dose conformity and the dosimetry of the heart and contralateral breast. More studies are needed to analyze whether these dosimetrical findings have clinical significance.

Cardiac doses of accelerated partial breast irradiation with perioperative multicatheter interstitial brachytherapy.

PURPOSE: To quantify mean heart dose (MHD) and doses to the left anterior descending artery (LAD) and left ventricle (LV) in a retrospective series of patients who underwent perioperative accelerated partial breast irradiation with multicatheter interstitial brachytherapy (MIB-APBI). METHODS: Sixty-eight patients with low-risk left breast cancer were treated with MIB-APBI at our institution between 2012 and 2017. Interstitial tubes were inserted during the tumorectomy and sentinel node biopsy and APBI was started 6 days later. The prescribed dose was 34 Gy in 10 fractions (twice a day) to the clinical target volume (CTV). The heart, LAD, and LV were contoured and the distance between each structure and the CTV was measured. The MHD, mean and maximum LAD doses (LAD mean/max), and mean LV doses (LV mean) were calculated and corrected to biologically equivalent doses in 2­Gy fractionation (EQD2). We also evaluated the impact of the distance between the cardiac structures and the CTV and of the volume receiving the prescribed dose (V100) and high-dose volume (V150) on heart dosimetry. RESULTS: Mean EQD2 for MHD, LAD mean/max, and mean LV were 0.9 ± 0.4 Gy (range 0.3-2.2), 1.6 ± 1.1 Gy (range, 0.4-5.6), 2.6 ± 1.9 Gy (range, 0.7-9.2), and 1.3 ± 0.6 Gy (range, 0.5-3.4), respectively. MHD, LAD mean/max, and LV mean significantly correlated with the distance between the CTV and these structures, but all doses were below the recommended limits (German Society of Radiation Oncology; DEGRO). The MHD and LV mean were significantly dependent on V100. CONCLUSION: Perioperative MIB-APBI resulted in low cardiac doses in our study. This finding provides further support for the value of this technique in well-selected patients with early-stage left breast cancer.

Radiation-induced breast angiosarcoma: report of two patients after accelerated partial breast irradiation (APBI) and review of the literature.

BACKGROUND: Angiosarcoma may rarely complicate radiotherapy of breast cancer. This so-called radiation-induced angiosarcoma (RIAS) occurs in less than 0.3% of patients that underwent breast conservation surgeries, usually years after completion of radiotherapy. CASE PRESENTATION: we introduce two cases of invasive ductal carcinoma who underwent lumpectomy and accelerated partial breast irradiation (APBI) as an alternative protocol to whole breast irradiation (WBI). They received adjuvant partial breast radiotherapy on tumor cavity for a total dose of 38.5 Gy in 10 fractions in 5 days using 3D-external-beam RT. In both cases, RIAS occurred eight years after radiotherapy, in the sub-cicatricial area in one patient and outside the irradiated area in the other one. They both underwent radical surgery and chemotherapy was performed in one patient. DISCUSSION: The underlying mechanism for development of RIAS is not well known, but its incidence seems to be increasing. RIAS after partial breast irradiation is very rare and has been reported in two cases so far. As it may be suggested in case 2, it is still a matter of debate if the risk of radiation-induced sarcoma is radiation-dose dependent. Although mastectomy is considered as a standard treatment, choice of treatment should be made according to the patient's specifications. CONCLUSION: There are very few studies in the literature that report RIAS after APBI. Present study is the only one reporting two cases after the external 3D technique APBI. Prognosis of RIAS remains poor. Only a careful evaluation in a multidisciplinary context can offer to the patients the best result in terms of local control and survival.

DEGRO practical guideline for partial-breast irradiation.

PURPOSE: This consensus statement from the Breast Cancer Working Group of the German Society for Radiation Oncology (DEGRO) aims to define practical guidelines for accelerated partial-breast irradiation (APBI). METHODS: Recent recommendations for relevant aspects of APBI were summarized and a panel of experts reviewed all the relevant literature. Panel members of the DEGRO experts participated in a series of conferences, supplemented their clinical experience, performed a literature review, and formulated recommendations for implementing APBI in clinical routine, focusing on patient selection, target definition, and treatment technique. RESULTS: Appropriate patient selection, target definition for different APBI techniques, and basic rules for appropriate APBI techniques for clinical routine outside of clinical trials are described. Detailed recommendations for APBI in daily practice, including dose constraints, are given. CONCLUSION: Guidelines are mandatory to assure optimal results of APBI using different techniques.

Accelerated partial breast irradiation by brachytherapy: present evidence and future developments.

Accelerated partial breast irradiation (APBI) delivers a short course of adjuvant RT after breast conserving surgery to only a limited part of the breast where the tumor was located. This procedure requires expertise, good communication, and close collaboration between specialized surgeons and attending radiation oncologists with adequate intraoperative tumor bed clip marking. However, APBI offers several intrinsic benefits when compared with whole breast irradiation (WBIR) including reduced treatment time (1 versus 4-6 weeks) and better sparing of surrounding healthy tissues. The present publication reviews the APBI level 1-evidence provided with various radiation techniques supplemented by long-term experience obtained from large multi-institutional phase II studies. Additionally, it offers an outlook on recent research with ultra-short or single-fraction APBI courses and new brachytherapy sources. Mature data from three randomized controlled trials (RCTs) clearly prove the noninferiority of APBI with 'only two techniques-1/MIBT (multicatheter interstitial brachytherapy) (two trials) and 2/intensity modulated radiotherapy (one trial)'-in terms of equivalent local control/overall survival to the previous standard 'conventionally fractionated WBIR'. However, MIBT-APBI techniques were superior in both toxicity and patient-reported outcomes (PROs) versus WBIR at long-term follow-up. Currently, in RCT-setting, alternative APBI techniques such as intraoperative electrons, 50-kV x-rays and three-dimensional conformal external beam radiotherapy (3D-CRT) failed to demonstrate noninferiority to conventionally fractionated WBIR. However, 3D-CRT-APBI compared noninferior to hypo-fractionated WBIR in preventing ipsilateral breast tumor recurrence (randomized RAPID-trial) but was associated with a higher rate of late radiation toxicity. Ultimately, MIBT remains the only APBI modality with noninferior survival/superior toxicity/PROs at 10-years and therefore should be prioritized over alternative methods in patients with breast cancer considered at low-risk for local recurrence according to recent international guidelines.

Consensus statement from the Spanish Brachytherapy Group (GEB) on accelerated partial breast irradiation using multicatheter interstitial brachytherapy.

AIM: To establish consensus guidelines for a safe clinical practice of accelerated partial breast irradiation (APBI) interstitial multicatheter brachytherapy (BT). BACKGROUND: APBI with interstitial multicatheter BT has proved to be effective in the treatment of early stage breast cancer. This paradigm shift in the approach to early breast cancer conservative treatment, along with the existing controversies on the clinical practice of APBI, prompted the Spanish Brachytherapy Group (GEB) of the Spanish Societies of Radiation Oncology (SEOR) and Medical Physics (SEFM) to address BT APBI in a consensus meeting. MATERIALS AND METHODS: Prior to the meeting, a survey with 27 questions on indication, inclusion criteria, BT modality, implant technique, image guidance and simulation, CTV and OAR definition, dose prescription and fractionation, dose calculation, implant quality metrics and OAR dose constrains was distributed. Items not reaching a level of agreement of 70% were discussed and voted during the meeting. RESULTS: 26 Institutions completed the survey, 60% of them perform APBI procedures. The analysis of the survey showed consensus reached on approximately half the questions. An expert panel discussed the remaining items; thereafter, a voting established the definite consensus. CONCLUSIONS: This document summarizes the consensus guidelines agreed during the meeting of the Spanish Brachytherapy Group SEOR-SEFM. Institutions with BT facilities available should offer interstitial BT APBI as a treatment option to patients fulfilling the inclusion criteria. Institutions willing to implement interstitial BT APBI are encouraged to follow the consensus guidelines established herein.

Tattoo free setup for partial breast irradiation: A feasibility study.

PURPOSE: Patients undergoing external beam accelerated partial breast irradiation (APBI) receive permanent tattoos to aid with daily setup alignment and verification. With the advent of three-dimensional (3D) body surface imaging and two-dimensional (2D) x-ray imaging-based matching to surgical clips, tattoos may not be necessary to ensure setup accuracy. We compared the accuracy of conventional tattoo-based setups to a patient setup without tattoos. MATERIALS/METHODS: Twenty consecutive patients receiving APBI at our institution from July 10, 2017 to February 13, 2018 were identified. All patients received tattoos per standard of care. Ten patients underwent setup using tattoos for initial positioning followed by surface imaging and 2D matching of surgical clips. The other ten patients underwent positioning using surface imaging followed by 2D matching without reference to tattoos. Overall setup time and orthogonal x-ray-based shifts after surface imaging per fraction were recorded. Shift data were used to calculate systematic and random error. RESULTS: Among ten patients in the "no tattoo" group, the average setup time per fraction was 6.83 min vs 8.03 min in the tattoo cohort (P < 0.01). Mean 3D vector shifts for patients in the "no tattoo" group were 4.6 vs 5.9 mm in the "tattoo" cohort (P = NS). Mean systematic errors in the "no tattoo" group were: 1.2 mm (1.5 mm SD) superior/inferior, 0.5 mm (1.6 mm SD) right/left, and 2.3 mm (1.9 mm SD) anterior/posterior directions. Mean systematic errors in the "tattoo" group were: 0.8 mm (2.2 mm SD) superior/inferior, 0.3 mm (2.5 mm SD) right/left, and 1.4 mm (4.4 mm SD) anterior/posterior directions. The random errors in the "no tattoo" group ranged from 0.6 to 0.7 mm vs 1.2 to 1.7 mm in the "tattoo" group. CONCLUSIONS: Using both surface imaging and 2D matching to surgical clips provides excellent accuracy in APBI patient alignment and setup verification with reduced setup time relative to the tattoo cohort. Skin-based tattoos may no longer be warranted for patients receiving external beam APBI.

Effectiveness of different accelerated partial breast irradiation techniques for the treatment of breast cancer patients: Systematic review using indirect comparisons of randomized clinical trials.

AIM: This systematic review was conducted to compare the effectiveness of different accelerated partial breast irradiation (APBI) techniques for the treatment of breast cancer patients. BACKGROUND: Numerous (APBI) techniques are available for clinical practice. METHODS AND MATERIALS: Systematic review of randomized controlled trials of APBI versus whole breast irradiation (WBI). The data from APBI studies were extracted for the analyses. Indirect comparisons were used to compare different APBI techniques. RESULTS: Ten studies fulfilled the inclusion criteria. A total of 4343 patients were included, most of them with tumor stage T1-T2 and N0. Regarding APBI techniques, six trials used external beam radiation therapy; one intraoperative electrons; one intraoperative low-energy photons; one brachytherapy; and one external beam radiation therapy or brachytherapy. The indirect comparisons related to 5-years local control and 5-years overall survival were not significantly different between APBI techniques. CONCLUSIONS: Based on indirect comparisons, no differences in clinical outcomes were observed among diverse APBI techniques in published clinical trials that formally compared WBI to APBI. However wide confidence intervals and high risk of inconsistency precluded a sound conclusion. Further head-to-head clinical trials comparing different APBI techniques are required to confirm our findings. Studies comparing different techniques using individual participant data and/or real-life data from population-based studies/registries could also provide more robust results.

Patient-reported outcomes of catheter-based accelerated partial breast brachytherapy and whole breast irradiation, a single institution experience.

PURPOSE: Accelerated partial breast irradiation (APBI) and whole breast irradiation (WBI) are treatment options for early-stage breast cancer. The purpose of this study was to compare patient-reported-outcomes (PRO) between patients receiving multi-channel intra-cavitary brachytherapy APBI or WBI. METHODS: Between 2012 and 2015, 131 patients with ductal carcinoma in situ (DCIS) or early stage invasive breast cancer were treated with adjuvant APBI (64) or WBI (67) and participated in a PRO questionnaire. The linear analog scale assessment (LASA), harvard breast cosmesis scale (HBCS), PRO-common terminology criteria for adverse events- PRO (PRO-CTCAE), and breast cancer treatment outcome scale (BCTOS) were used to assess quality of life (QoL), pain, fatigue, aesthetic and functional status, and breast cosmesis. Comparisons of PROs were performed using t-tests, Wilcoxon rank-sum, Chi square, Fisher exact test, and regression methods. RESULTS: Median follow-up from completion of radiotherapy and questionnaire completion was 13.3 months. There was no significant difference in QoL, pain, or fatigue severity, as assessed by the LASA, between treatment groups (p > 0.05). No factors were found to be predictive of overall QoL on regression analysis. BCTOS health-related QoL scores were similar between treatment groups (p = 0.52).The majority of APBI and WBI patients reported excellent/good breast cosmesis, 88.5% versus 93.7% (p = 0.37). Skin color change (p = 0.011) and breast elevation (p = 0.01) relative to baseline were more common in the group receiving WBI. CONCLUSIONS: APBI and WBI were both associated with favorable patient-reported outcomes in early follow-up. APBI resulted in a lesser degree of patient-reported skin color change and breast elevation relative to baseline.

Synchronous bilateral breast cancer patients submitted to conservative treatment and brachytherapy - The experience of a service.

INTRODUCTION: The incidence of breast carcinoma (BC) has increased in the last years. Between 2 and 12% of patients diagnosed with BC will develop bilateral breast carcinoma (BBC). The treatment of these carcinomas is more aggressive than unilateral BC. PURPOSE: To perform a retrospective qualitative analysis of BBC patients whose treatment has included brachytherapy (BT) and to present a revised literature on this issue. MATERIAL AND METHODS: The cases of BBC whose treatment included brachytherapy were revised. The literature on this issue was refreshed. RESULTS: Five women, aged between 54 and 78 at the time of the diagnosis, submitted to conservative surgery followed by external radiotherapy (RT) with boost of BT or exclusive BT (APBI), in the IPO-P BT Service between 2003 and 2016. DISCUSSION: The patients with BBC have slightly higher rates of local recurrences, mostly in the tumor bed, where there is a higher risk of local recurrence. Patients treated with BT had lower rates of recurrences than those treated with photons and electrons. CONCLUSIONS: BBC represents a complex challenge for doctors, because in some cases there is a tendency to use more aggressive treatments and, at the same time, it is not easy to achieve the timing for the correct treatment.

Implementation of image-guided intensity-modulated accelerated partial breast irradiation : Three-year results of a phase II clinical study.

PURPOSE: To report 3­year results of accelerated partial breast irradiation (APBI) using image-guided intensity-modulated radiotherapy (IG-IMRT) following breast conserving surgery (BCS) for low-risk early invasive breast cancer. PATIENTS AND METHODS: Between July 2011 and March 2014, 60 patients with low-risk early invasive breast cancer underwent BCS and were enrolled in this phase II prospective study. The total dose was 36.9 Gy (9 fractions of 4.1 Gy, two fractions/day). Patient setup errors were detected in LAT, LONG and VERT directions. Local tumour control, survival results, early and late side effects and cosmetic outcome were assessed. RESULTS: At a median follow-up of 39 months, all patients were alive and neither locoregional nor distant failure occurred. One contralateral breast cancer and two new primary malignancies outside the breast were observed. No grade (G) 3-4 acute toxicity was detected. G1 and G2 erythema occurred in 21 (35%) and 2 (3.3%) patients, respectively; while G1 oedema was observed in 23 (38.8%) cases. G1 and G2 pain was reported by 6 (10%) and 2 (3.3%) patients, respectively. Among the late radiation side effects, G1 pigmentation or telangiectasia, G1 fibrosis and G1 asymptomatic fat necrosis occurred in 10 (16.7%), 7 (11.7%) and 3 (5%) patients, respectively. No ≥ G2 late toxicity was detected. Cosmetic outcome was excellent in 43 (71.7%) and good in 17 (28.3%) patients. CONCLUSION: IG-IMRT is a reproducible and feasible technique for delivery of external beam APBI following BCS for treatment of low-risk, early-stage invasive breast carcinoma. In order to avoid toxicity, image guidance performed before each radiation fraction is necessary to minimize the PTV. Three-year results are promising, early and late radiation side-effects are minimal, and cosmetic results are excellent to good.

Factors predictive of failure to complete planned intraoperative breast radiation using the intrabeam® system.

PURPOSE: Intraoperative radiation therapy (IORT) is a form of breast irradiation that is delivered in a single session at the time of partial mastectomy. In up to 10% of patients, planned IORT is not completed; this leads to wasted resources and decreased patient satisfaction. Our objective was to evaluate factors associated with failure to complete planned IORT. METHODS AND MATERIALS: An IRB-approved review of planned IORT cases from 2011 to 2015 was conducted. Eligibility criteria included: age ≥60, invasive ductal or mammary carcinoma, tumor <3.0 cm, ER positive, and clinically node negative. Discontinuation of planned IORT was at the discretion of the breast surgical and radiation oncologists. RESULTS: Twenty-one (15%) of one hundred and forty-five planned IORT cases were not completed. Reasons for failure to complete IORT included inadequate applicator to skin distance (n = 15, 71%), altered wire localization findings the day of surgery (n = 4, 19%), equipment failure (n = 1, 5%), and hemodynamic instability (n = 1, 5%). Significant surgeon variability was associated with failure to complete planned IORT (P < 0.001). CONCLUSIONS: Insufficient skin-to-applicator spacing is the most common reason for failure to complete IORT. In this series, higher volume surgeons completed a greater proportion of IORT cases, suggesting a learning curve to patient selection or intraoperative technique. J. Surg. Oncol. 2016;114:930-932. © 2016 Wiley Periodicals, Inc.

Ultrasound-Guided Placement of Gold Fiducial Markers for Stereotactic Partial-Breast Irradiation.

OBJECTIVE: A novel technique of placing gold fiducial markers in the breast using ultrasound guidance was developed and performed in 51 of 55 consecutive postlumpectomy patients enrolled in a phase I dose escalation trial of accelerated partial-breast irradiation (APBI) using robotic-based stereotactic body radiation therapy (SBRT). CONCLUSION: All 51 postoperative patients underwent successful fiducial placement without complications. Our technique of placing gold fiducial markers in proximity to the seroma cavity is considered safe and effective for breast cancer patients being treated with APBI using robotic-based SBRT.

Techniques for intraoperative radiation therapy for early-stage breast carcinoma.

Intraoperative radiation therapy (IORT) is a method of accelerated partial breast irradiation developed to replace other longer courses of radiotherapy with a single radiation session administered at the time of breast-conserving surgery. The purpose of this review is to summarize the advantages and disadvantages of breast IORT techniques that are currently available, as well to consider potential alternative techniques for breast IORT or ultra-short course breast radiotherapy. Furthermore, we highlight the published outcomes for the IORT treatment approaches including: electron therapy, superficial photon therapy and other techniques. Potential future directions of IORT are explored including novel IORT techniques utilizing intraoperative brachytherapy with in-room imaging and rapid treatment planning.

Brachytherapy in breast cancer: an effective alternative.

Breast conserving surgery (BCS) with following external beam radiation therapy (EBRT) of the conserved breast has become widely accepted in the last decades for the treatment of early invasive breast cancer. The standard technique of EBRT after BCS is to treat the whole breast up to a total dose of 42.5 to 50 Gy. An additional dose is given to treated volume as a boost to a portion of the breast. In the early stage of breast cancer, research has shown that the area requiring radiation treatment to prevent the cancer from local recurrence is the breast tissue that surrounds the area where the initial cancer was removed. Accelerated partial breast irradiation (APBI) is an approach that treats only the lumpectomy bed plus a 1-2 cm margin rather than the whole breast and as a result allows accelerated delivery of the radiation dose in four to five days. There has been a growing interest for APBI and various approaches have been developed under phase I-III clinical studies; these include multicatheter interstitial brachytherapy, balloon catheter brachytherapy, conformal external beam radiation therapy (3D-EBRT) and intra-operative radiation therapy (IORT). Balloon-based brachytherapy approaches include MammoSite, Axxent electronic brachytherapy, Contura, hybrid brachytherapy devices. Another indication for breast brachytherapy is reirradiation of local recurrence after mastectomy. Published results of brachytherapy are very promising. We discuss the current status, indications, and technical aspects of breast cancer brachytherapy.