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Five-Fraction Prone Accelerated Partial Breast Irradiation: Long-Term Oncologic, Dosimetric, and Cosmetic Outcome

Shah, Bhartesh A; Xiao, Julie; Oh, Cheongeun; Taneja, Sameer; Barbee, David; Maisonet, Olivier; Huppert, Nelly; Perez, Carmen; Gerber, Naamit K
PURPOSE/OBJECTIVE:Randomized data support accelerated partial breast irradiation (APBI) for early-stage breast cancer with variable techniques and cosmesis outcomes. We have treated patients with 5-fraction prone external beam APBI for over a decade and herein report acute and late outcomes. METHODS AND MATERIALS/METHODS:Patients receiving APBI 600 cGy × 5 between 2010 and 2019 were included. APBI was primarily delivered prone, with opposed tangents targeting the tumor bed expanded by 1.5 cm (cropped 6 mm from skin). Ipsilateral breast was constrained to V50% < 60% and V100% < 35%. Survival was estimated with Kaplan-Meier. Late toxicities and clinician- and patient-rated cosmesis were evaluated for patients with >6 months follow-up (FU). RESULTS:Of 345 patients meeting criteria, 14 were excluded due to APBI given for ipsilateral breast tumor recurrence (IBTR; n = 3), palliation (n = 9), and incomplete radiation therapy course (n = 2). Of the 331 remaining, median age was 70, 7.2% had ductal carcinoma in situ, and 94.3% were treated prone, with 32% treated every other day and 68% on consecutive days. Mean heart dose was 23.8 cGy for left-sided and 12.7 cGy for right-sided cancers. Ipsilateral lung V30% was 0.4%. At 5-year median FU, there were 7 (2.1%) IBTR, 9 (2.7%) contralateral recurrences, and 1 (0.3%) distant metastasis. Five-year local recurrence-free, disease-free, and overall survival was 99.5%, 96.7%, and 98.1%, respectively. When comparing patients with IBTR versus without, a higher proportion did not receive hormone therapy (71.4% vs. 26.2%, P = .018). Rates of acute grade 1 to 2 dermatitis, fatigue, and pain were 35.4%, 21.8%, and 9.4%, respectively, with no grade 3 toxicity. The rate of good-excellent physician- and patient-rated cosmesis (n = 199, median FU 2.8 years) was 92.5% and 89.4%, respectively. Patients experienced low rates of telangiectasia, fibrosis, and retraction/atrophy. CONCLUSIONS:We report excellent dosimetric, oncologic, cosmetic, and late toxicity outcomes for patients treated with 5-fraction APBI. To our knowledge this is the largest series of women treated with prone APBI.
PMID: 34474168
ISSN: 1879-8519
CID: 5026612

A prospective trial to compare deep inspiratory breath hold (DIBH) with prone breast irradiation

Gerber, Naamit K; Yan, Sherry X; Levinson, Benjamin A; Perez, Carmen A; Das, Indra J; Maisonet, Olivier G; Huppert, Nelly; No, Diana K; Kelley, Jessica; Mistry, Neha; Hitchen, Christine J; Goldberg, Judith D
PURPOSE/OBJECTIVE:To compare heart and lung doses for adjuvant whole breast irradiation (WBI) between radiation plans generated supine with deep inspiratory breath hold (S-DIBH) and prone with free-breathing (P-FB) and examine the effect of breast volume (BV) on dosimetric parameters. MATERIALS/METHODS/METHODS:Patients with left breast DCIS or invasive cancer receiving adjuvant WBI were enrolled on a single-institutional prospective protocol. Patients were simulated S-DIBH and P-FB; plans were generated using both scans. Wilcoxon's Signed Rank and Rank Sum tests were used to compare intra-patient differences between plans for the entire cohort and within BV groups defined by tertiles. RESULTS:Forty patients were enrolled. Thirty-four patients are included in the analysis due to patient withdrawal or inability to hold breath. With WBI dose of 4005 - 4256 cGy, mean heart dose (MHD) was 80 cGy in S-DIBH, 77 cGy in P-FB (p=0.08). Mean ipsilateral lung dose (MLD) was 453 cGy in S-DIBH, 45 cGy in P-FB (p<0.0001). Mean and max LAD dose were 251 cGy and 551 cGy in S-DIBH respectively, 324 cGy (p=0.1) and 993 cGy in P-FB (p=0.3) respectively. Hot spot and separation was 109% and 22 cm in S-DIBH respectively, 107% and 16 cm in P-FB respectively (p<0.0001). For patients with smallest BV, S-DIBH improved MHD and LAD doses; for those with largest BV, P-FB improved cardiac dosimetry. With increasing BV, there was an increasing advantage of P-FB for MHD (p=0.05), and max (p=0.03) and mean (p=0.02) LAD dose, and the reduction in MLD, hot spot, and separation with P-FB increased (p<0.05). CONCLUSIONS:MHD did not differ between P-FB and S-DIBH, whereas MLD was significantly lower with P-FB. Analysis according to breast volume revealed improved cardiac dosimetry with S-DIBH for women with smallest BV and improved cardiac dosimetry with P-FB for women with larger BV, thereby providing a dosimetric rationale for using breast size to help determine the optimal positioning for WBI.
PMID: 32014615
ISSN: 1879-8519
CID: 4299902

Radiation effect on late cardiopulmonary toxicity: An analysis comparing supine DIBH versus prone techniques for breast treatment

Yan, Sherry X; Maisonet, Olivier G; Perez, Carmen A; Huppert, Nelly; Hitchen, Christine J; Das, Indra J; Gerber, Naamit K
Two commonly used whole breast irradiation (WBI) techniques, deep inspiration breath hold (DIBH) and prone positioning, are compared with regard to dosimetry and estimated late cardiac morbidity and secondary lung cancer mortality using published models. Forty patients with left-sided DCIS or breast cancer who underwent lumpectomy and required adjuvant WBI were enrolled on a prospective trial comparing supine DIBH (S-DIBH) with prone free breathing (P-FB) planning. Patients underwent CT simulation in both positions; two plans were generated for each patient. Comparative dosimetry was available for 34 patients. Mean cardiac and lung doses were calculated. Risk of death from ischemic heart disease (IHD), risk of at least one acute coronary event (ACE), and lung cancer mortality were estimated from published data. Difference between S-DIBH and P-FB plans was compared using paired two-tailed t test. Estimated mean risk of death from IHD by age 80 was 0.1% (range 0.0%-0.2%) for both plans (P = 1.0). Mean risk of at least one ACE was 0.3% (range 0.1%-0.6%) for both plans (P = .6). Mean lung cancer mortality risk was 1.4% (range 0.5%-15.4%) for S-DIBH and 1.0% (range 0.4%-9.8%) for P-FB (P = .008). Excess lung cancer mortality due to radiation was 0.5% (range 0.1%-6.0%) with S-DIBH and 0.0% (range 0.0%-0.4%) with P-FB (P = .008). Both S-DIBH and P-FB provide excellent cardiac sparing. Prone positioning results in lower lung dose than S-DIBH and leads to an absolute decrease of 0.5% in excess lung cancer mortality for patients receiving WBI.
PMID: 31912595
ISSN: 1524-4741
CID: 4257322

Ipsilateral breast tumor recurrence in early stage breast cancer patients treated with breast conserving surgery and adjuvant radiation therapy: Concordance of biomarkers and tumor location from primary tumor to in-breast tumor recurrence

Purswani, Juhi M; Shaikh, Fauzia; Wu, S Peter; Kim, Jennifer Chun; Schnabel, Freya; Huppert, Nelly; Perez, Carmen A; Gerber, Naamit K
BACKGROUND:Patients with an in-breast tumor recurrence (IBTR) after breast-conserving therapy have a high risk of distant metastasis and disease-related mortality. Classifying clinical parameters that increase risk for recurrence after IBTR remains a challenge. AIM/OBJECTIVE:To describe primary and recurrent tumor characteristics in patients who experience an IBTR and understand the relationship between these characteristics and disease outcomes. METHODS:Patients with stage 0-II breast cancer treated with lumpectomy and adjuvant radiation were identified from institutional databases of patients treated from 2003-2017 at our institution. Overall survival (OS), disease-free survival, and local recurrence-free survival (LRFS) were estimated using the Kaplan Meier method. We identified patients who experienced an isolated IBTR. Concordance of hormone receptor status and location of tumor from primary to recurrence was evaluated. The effect of clinical and treatment parameters on disease outcomes was also evaluated. RESULTS:= 0.004) decreased the risk of IBTR. CONCLUSION/CONCLUSIONS:Among patients with early stage breast cancer who had breast conserving surgery treated with adjuvant RT, ER/PR status and quadrant were highly concordant from primary to IBTR. Tumor size greater than 1.5 cm and use of adjuvant endocrine therapy were significantly associated with decreased risk of IBTR.
PMID: 31976307
ISSN: 2218-4333
CID: 4273472

Whole breast irradiation with high tangents in the prone position

Shaikh, Fauzia; Tam, Moses; Taneja, Sameer; Huppert, Nelly; McCarthy, Allison; Hitchen, Christine; Maisonet, Olivier; Perez, Carmen; Barbee, David; Gerber, Naamit Kurshan
ISSN: 1948-7894
CID: 4898682

Hypofractionated Whole-Breast Irradiation in Women Less Than 50 Years Old Treated on 4 Prospective Protocols

Shaikh, Fauzia; Chew, Jessica; Hochman, Tsivia; Purswani, Juhi; Maisonet, Olivier; Peat, Elecia; Huppert, Nelly; Cooper, Benjamin T; Tam, Moses; Goldberg, Judith D; Perez, Carmen A; Formenti, Silvia C; Gerber, Naamit K
PURPOSE/OBJECTIVE:Hypofractionated whole-breast radiation therapy (RT) has proved to be equivalent to conventionally fractionated RT in multiple randomized trials. There is controversy regarding its use in younger women because of their underrepresentation in trials and the concern for late toxicity. We evaluated disease control and cosmetic outcomes in patients aged <50 years treated with hypofractionated RT in 4 prospective single-institutional trials. METHODS AND MATERIALS/METHODS:From 2003 to 2015, 1313 patients were enrolled in 4 prospective protocols investigating the use of adjuvant hypofractionated RT after breast-conserving surgery with a daily or weekly concomitant boost. We identified the records of 348 patients aged <50 years at consultation for this analysis. Overall survival, disease-free survival, and local recurrence-free survival were estimated using the Kaplan-Meier method by study and across studies using meta-analytic methods. The late effects of RT, clinician-rated cosmesis, and patient-rated cosmesis were also evaluated. RESULTS:With a median follow-up period of 66.9 months, the overall survival rate was 99.6%, the disease-free survival rate was 96.3%, and the local recurrence-free survival rate was 97.7% at 3 years. Clinician-rated cosmesis (n = 242) was excellent or good in 93.4% of cases and fair or poor in 6.6%. Patient-rated cosmesis (n = 259) was excellent or good in 86.1% and fair or poor in 13.9%. When patients rated themselves differently than their physicians, patients more often rated themselves poorly compared with their physicians (P = .0044, Cochran-Mantel-Haenszel test). CONCLUSIONS:At a median follow-up of 5 years, an analysis of patients aged <50 years demonstrated that hypofractionated RT was safe and effective, with good to excellent cosmesis as assessed by both clinicians and patients.
PMID: 29859789
ISSN: 1879-355x
CID: 3144252

A Comparison of the Pathologic Response Rate After Neoadjuvant Chemoradiation in Patients with Locally Advanced Breast Cancer in an Underserved Population [Meeting Abstract]

Keshinro, A; Huppert, N; Dhage, S; Formenti, S; Joseph, K
ISSN: 1534-4681
CID: 1930992

Prospective Randomized Trial of Prone Accelerated Whole Breast Radiation Therapy With a Concurrent Daily Versus Weekly Boost to the Tumor Bed: Acute Toxicity [Meeting Abstract]

Osa, E. O.; Huppert, N.; Fenton-Kerimian, M.; Goldberg, J. D.; Jozsef, G.; DeWyngaert, K.; Formenti, S. C.
ISSN: 0360-3016
CID: 204852

Pathologic response rate in HER2-positive locally advanced breast cancers treated with neoadjuvant trastuzumab and concurrent paclitaxel/radiotherapy [Meeting Abstract]

Adams, Sylvia; Hochman, Tsivia; Huppert, Nelly; Dhage, Shubhada; Checka, Cristina; Singh, Baljit; Speyer, James L; Schneider, Robert; Goldberg, Judith D; Formenti, Silvia
ISSN: 0732-183x
CID: 1675552

The role of a prone setup in breast radiation therapy

Huppert, Nelly; Jozsef, Gabor; Dewyngaert, Keith; Formenti, Silvia Chiara
Most patients undergoing breast conservation therapy receive radiotherapy in the supine position. Historically, prone breast irradiation has been advocated for women with large pendulous breasts in order to decrease acute and late toxicities. With the advent of CT planning, the prone technique has become both feasible and reproducible. It was shown to be advantageous not only for women with larger breasts but in most patients since it consistently reduces, if not eliminates, the inclusion of heart and lung within the field. The prone setup has been accepted as the best localizing position for both MRI and stereotactic biopsy, but its adoption has been delayed in radiotherapy. New technological advances including image-modulated radiation therapy and image-guided radiation therapy have made possible the exploration of accelerated fractionation schemes with a concomitant boost to the tumor bed in the prone position, along with better imaging and verification of reproducibility of patient setup. This review describes some of the available techniques for prone breast radiotherapy and the available experience in their application. The NYU prone breast radiotherapy approach is discussed, including a summary of the results from several prospective trials.
PMID: 22655240
ISSN: 2234-943x
CID: 169256