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Background and purpose: Accelerated partial breast irradiation (APBI) may benefit from the MR-Linac for target definition, patient setup, and motion monitoring. In this planning study, we investigated whether prone or supine position is dosimetrically beneficial for APBI on an MR-Linac and we evaluated patient comfort. Materials and methods: Twenty-patients (9 postoperative, 11 preoperative) with a DCIS or breast tumor

Cell-in-cell (CIC) structures in breast cancer have so far been studied in a small inhomogeneous patient population, suggesting the prognostic importance of CIC. In the present study, we focused on CIC in early hormone-sensitive breast cancer. With in vitro co-culture experiments, we compared the homotypic phagocytic capacity of two breast cancer cell lines to that of primary human fibroblasts. Afterward, we studied 601 tissue specimens from 147 patients participating in an institutional accelerated partial breast irradiation (APBI) phase II trial. Both breast cancer cell lines performed non-professional phagocytosis at a higher rate than primary human fibroblasts. In this study cohort, 93.2% of the patients had T1 tumours, and 6.8% had T2 tumours. CIC was found in 61.2% of the patients, with a CIC rate ranging from

Introduction The aim of this study is to evaluate the characteristics of the dosimetry and the skin dose of interstitial brachytherapy by the use of the free‐hand implantation technique toward the treatment of early breast cancer. Materials & Methods Seventeen patients diagnosed with early breast cancer were selected for the study. The implantation of the catheters for postoperative interstitial brachytherapy was performed using the free‐hand technique. The total tumor dose to the tumor cavity plus 2 cm margin was 3400 cGy, twice daily for 10 fractions in 5 days. The dosage to the target and the organ at risk (OAR) were recorded for analysis. The skin dose of the patient and the phantom were measured with Gafchromic film (EBT3) and the results were compared with the skin dose calculated by the brachytherapy treatment planning system. Results The median conformal index is 94% (range 89%–99%), and the median homogeneity index is 71%. The median skin dose measured from the skin of the patients was 20.1% lower than the skin dose calculated from the treatment planning system and consistent with the phantom surface measurement experiment. There were no grade 3 or above acute toxicity recorded. Conclusions Interstitial brachytherapy by the use of the free‐hand implantation technique for early breast cancer is feasible and avoids the need for a second surgical intervention. The calculated skin dose was overestimated by at least 20%. The results of this study may help in building a modification model for the prediction of skin toxicity in any future study.

Purpose: To compare health-related quality of life (HRQL) in elderly breast cancer patients between two types of Accelerated Partial Breast Irradiation: intraoperative radiotherapy (IORT) and external beam APBI (EB-APBI).Methods: Between 2011 and 2016 women >= 60 years undergoing breast conserving therapy for early stage breast cancer were included in a prospective multi-centre cohort study. Patients were treated with electron IORT (1 x 23.3 Gy) or photon EB-APBI (10 x 3.85 Gy daily). HRQL was measured by the EORTC-QLQ C30 and BR23 questionnaires before surgery and at several time points until 1 year.Results: HRQoL data was available of 204 IORT and 158 EB-APBI patients. In longitudinal analyses emotional functioning and future perspective were significantly, but not clinically relevantly, worse in IORT-treated patients, and improved significantly during follow-up in both groups. All other aspects of HRQL slightly worsened after treatment and recovered within 3 months with an improvement until 1 year. Cross-sectional analysis showed that postoperatively fatigue and role functioning were significantly worse in IORT patients compared to EB-APBI patients who were not yet irradiated, but the difference was not clinically relevant. At other timepoints there were no significant differences. Multivariable analysis at 1 year identified comorbidity and systemic therapy as risk factors for a worse global health score (GHS).Conclusions: EB-APBI and IORT were well tolerated. Despite a temporary deterioration after treatment, all HRQL scales recovered within 3 months resulting in no clinically relevant differences until 1 year between groups nor compared to baseline levels. (C) 2019 Elsevier Ltd. All rights reserved.

Background The aim of the study was to individualize accelerated partial breast irradiation based on optimal dose distribution, protect risk organ and predict most advantageous technique. Materials and methods 138 breast cancer patients receiving postoperative APBI were enrolled. APBI plans were generated using 3D-conformal (3D-CRT), sliding window intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (VMAT). In the case of superficial tumours, additional plans were developed by adding electron beam. To planning target volume (PTV) 37.5 Gy/10 fractions, 1 fraction/day was prescribed. A novel plan quality index (PQI) served as the basis for comparisons. Results IMRT was the most advantageous technique regarding homogeneity. VMAT provided best conformity, 3D-CR T — the lowest lung and heart exposure. PQI was the best in 45 (32.61%) VMAT, 13 (9.42%) IMRT, 9 (6.52%) 3D-CRT plans. In 71 cases (51.45%) no difference was detected. In patients with large PTV, 3D-CRT was the most favourable. Additional electron beam improved PQI of 3D-CRT plans but had no meaningful effect on IMRT or VMAT. IMRT was superior to VMAT if the tumour was superficial (p < 0.001), situated in the medial (p = 0.032) or upper quadrant (p = 0.046). Conclusions In half of all cases, individually selected teletherapy techniques provide superior results over others; relevance of a certain technique may be predicted by volume and PTV localization.

Purpose To evaluate and compare health-related quality of life (HRQL) of women with early-stage breast cancer (BC) treated with different radiotherapy (RT) regimens. Methods Data were collected from five prospective cohorts of BC patients treated with breast-conserving surgery and different RT regimens: intraoperative RT (IORT, 1 × 23.3 Gy; n = 267), external beam accelerated partial breast irradiation (EB-APBI, 10 × 3.85 Gy; n = 206), hypofractionated whole breast irradiation(hypo-WBI, 16 × 2.67 Gy; n = 375), hypo-WBI + boost(hypo-WBI-B, 21–26 × 2.67 Gy; n = 189), and simultaneous WBI + boost(WBI-B, 28 × 2.3 Gy; n = 475). Women ≥ 60 years with invasive/in situ carcinoma ≤ 30 mm, cN0 and pN0-1a were included. Validated EORTC QLQ-C30/BR23 questionnaires were used to asses HRQL. Multivariable linear regression models adjusted for confounding (age, comorbidity, pT, locoregional treatment, systemic therapy) were used to compare the impact of the RT regimens on HRQL at 12 and 24 months. Differences in HRQL over time (3–24 months) were evaluated using linear mixed models. Results There were no significant differences in HRQL at 12 months between groups except for breast symptoms which were better after IORT and EB-APBI compared to hypo-WBI at 12 months (p

Background The aim of the study was to evaluate and compare four different external beam radiotherapy techniques of accelerated partial breast irradiation (APBI) considering target coverage, dose to organs at risk and overall plan quality. The investigated techniques were three dimensional conformal radiotherapy (3D-CRT), “step and shoot” (SS) and “sliding window” (SW) intensity-modulated radiotherapy (IMRT), intensity-modulated arc therapy (RA). Patients and methods CT scans of 40 APBI patients were selected for the study. The planning objectives were set up according to the international recommendations. Homogeneity, conformity and plan quality indices were calculated from volumetric and dosimetric parameters of target volumes and organs at risk. The total monitor units and feasibility were also investigated. Results There were no significant differences in the coverage of the target volume between the techniques. The homogeneity indices of 3D-CRT, SS, SW and RA plans were 0.068, 0.074, 0.058 and 0.081, respectively. The conformation numbers were 0.60, 0.80, 0.82 and 0.89, respectively. The V50% values of the ipsilateral breast for 3D-CRT, SS, SW and RA were 47.5%, 40.2%, 39.9% and 31.6%, respectively. The average V10% and V40% values of ipsilateral lung were 13.1%, 28.1%, 28%, 36% and 2.6%, 1.9%, 1.9%, 3%, respectively. The 3D-CRT technique provided the best heart protection, especially in the low dose region. All contralateral organs received low doses. The SW technique achieved the best plan quality index (PQI). Conclusions Good target volume coverage and tolerable dose to the organs at risk are achievable with all four techniques. Taking into account all aspects, we recommend the SW IMRT technique for APBI.

Purpose To compare cardiac doses of different whole-breast optimization schemes including free-breathing (FB) tangential radiotherapy (TRT), deep-inspiration breath-hold (DIBH) TRT, and FB helical tomotherapy (HT). Methods Early-stage left-sided breast cancer patients who underwent breast-conserving surgery followed by adjuvant radiotherapy were included in the study. Planning images included FB and DIBH CT scans acquired in the same supine treatment position with both arms abducted. A hypofractionated regimen of 42.5 Gy in 16 fractions was used. Clinical target volume delineation was aided through the use of a radio-opaque wire. A 7-mm margin was used in generating the planning target volumes. TRT plans were generated both in FB and DIBH. For the FB tomotherapy technique, a first plan (Tomo 1) was optimized limiting the maximum contralateral breast dose to 3.1 Gy. A second tomotherapy plan (Tomo 2) focused on the reduction of the mean heart dose without controlling the contralateral breast dose. All plans were optimized to obtain an equivalent planning target volume (PTV) coverage of ≥95% of the prescribed dose while minimizing the dose to organs at risk. Results Twenty-three patients treated between October 2012 and March 2016 were included in this retrospective study. Eleven patients (48%) had at least one major cardiovascular risk factors including one patient (4%) with a history of myocardial infarction. Six patients (26%) had been exposed to cardiotoxic chemotherapy agents. The average mean dose to the heart was 3.1 Gy with FB TRT, 1.1 with DIBH TRT, 2.4 Gy for Tomo 1, and 1.5 Gy for Tomo 2. The mean dose to the left anterior descending artery was 27.0 Gy, 8.0 Gy, 13.7 Gy and 6.6 Gy for FB TRT, DIBH TRT, Tomo 1 and Tomo 2 plans respectively. Conclusion Different cardiac-sparing optimization schemes are possible when treating left breast cancer. Although DIBH offers clear mean heart dose reductions, tomotherapy can be an interesting alternative treatment modality to spare the heart and coronary vessels, notably in patients who cannot comply with DIBH.

Purpose The aim of the present work is to assess the Objective Breast Cosmesis Scale (OBCS) in a patient cohort that was treated in two hospitals. Their treatment-related cosmetic changes were recorded on nonstandardized photographs. Methods and Materials Nineteen female patients were enrolled in two radiation oncology centers (Nice, France, and Perugia, Italy). All patients had undergone breast-conserving surgery (BCS) and received adjuvant accelerated partial breast irradiation using interstitial fractionated multicatheter high-dose-rate brachytherapy. One photograph before and another after accelerated partial breast irradiation was taken for each patient to record changes in breast cosmesis. Using the OBCS, before and after photographs were analyzed by measuring distances between anatomic features. OBCS scores from four doctors (two males [one radiation oncologist and one post-grad trainee] and two females [one radiation oncologist and one post-grad trainee]) were compared. Results Agreement was high between trainees and specialist, and males and females before and after treatment. The intraclass correlation coefficient ranged from 0.867 to 0.950 before treatment and from 0.876 to 0.952 afterward. The coefficient of variation ranged from 12% to 26.5% before treatment, and from 13% to 21.4% afterward. Conclusions The OBCS is easy, time-efficient, reproducible, cost-effective, and reliable. Its potential practical applications merit further investigation in future studies.

Background and purpose We investigated the acute toxicity of accelerated partial breast irradiation using external beam (EB-APBI) or intraoperative radiotherapy (IORT) techniques in elderly breast cancer patients. Materials and methods Women ≥ 60 years with unifocal breast tumors of ≤ 30 mm were eligible for this prospective multi-center cohort study. IORT was applied with electrons following lumpectomy (23.3 Gy). EB-APBI was delivered using 3D-CRT or IMRT in 10 daily fractions of 3.85 Gy within 6 weeks after surgery. Acute toxicity was scored using the CTCAE v3.0 at 3 months after treatment. Patient-reported symptoms were analyzed using visual analogue scales (VAS) for pain and fatigue (scale 0–10), and single items from the EORTC QLQ-C30 and Breast Cancer questionnaires. Results In total, 267 (IORT) and 206 (EB-APBI) patients were available for toxicity analysis. More patients experienced ≥ grade 2 CTCAE acute toxicity in the IORT group (10.4% IORT and 4.9% EB-APBI; p = 0.03); grade 3 toxicity was low (3.3% IORT and 1.5% EB-APBI; ns); and no grade 4 toxicity occurred. EB-APBI patients experienced less fatigue direct postoperatively (EORTC p

Introduction: For early stage breast cancer patients, non-breast cancer mortality including secondary cancers and cardiac events can overshadow the benefit of adjuvant radiotherapy. This study evaluates the excess risk of secondary cancer for various breast radiotherapy techniques including accelerated partial breast irradiation (APBI).Methods: Secondary cancers Lifetime Attributable Risks (LAR) were calculated using a modified BEIR-VII formalism to account for the specific survival of breast cancer patients. Those survivals were extracted from the SEER database. Doses scattered to various organs were measured into a Rando phantom with custom-made breast phantoms. Treatments delivered typical doses of brachytherapy APBI (34 Gy in 10 fractions), external beam APBI (38.5 Gy in 10 fractions) using 3D-conformal, Cyberknife stereotactic (CK), or VMAT, as well as whole breast irradiation (WBI) delivering 42.5 Gy in 16 fractions.Results: WBI resulted in the highest total LAR, with 4.3% excess risk of secondary cancer for a patient treated at age 50 years. Lung cancers accounted for 75-97% of secondary malignancies. For a typical early stage patient irradiated at 50, the excess risks of secondary lung cancer were 1.1% for multicatheter HDR, between 2.2% and 2.5% for 3D-CRT or CK, 3.5% for VMAT APBI, and 3.8% for WBI.Conclusions: APBI reduces the risk of secondary cancer 2-4 fold compared to WBI. These techniques are well suited for long-living early stage breast cancer patients. HDR brachytherapy and 3D-conformal APBI achieve mean lung doses between 1 and 1.5 Gy, which could serve as reference. (C) 2018 Elsevier B.V. All rights reserved.

// Gengchun Liu 1, * , Zhongyi Dong 2, * , Baqun Huang 1 , Yuelong Liu 1 , Yan Tang 1 , Qing Li 1 and Yihui Zhu 1 1 Department of Radiation Oncology, Xiangtan City Central Hospital, Xiangtan 411100, Hunan Province, China 2 Department of Radiation Oncology, Nonfan Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China * These authors contributed equally to this work Correspondence to: Gengchun Liu, email: for-magi@outlook.com Keywords: efficacy, safety, accelerated partial breast irradiation, meta-analysis Received: March 16, 2017 Accepted: June 29, 2017 Published: July 13, 2017 ABSTRACT Background and purpose: Accelerated partial breast irradiation (APBI) technology has theoretical advantages in comparison with traditional adjuvant radiation therapy (whole-breast irradiation; WBI) after breast-conserving surgery. However, published randomized controlled trials have shown inconsistent outcomes. Therefore, a comprehensive assessment of the effectiveness and safety of APBI technology is needed. Results: A total of 7 studies of 7452 patients were included in this analysis. All 7 studies reported local recurrence as an outcome. Meta-analysis of 5 trials that included 6486 patients showed significantly different 5-year local recurrence rates for APBI and WBI groups (hazard ratio = 4.54, 95% confidence interval: 1.78–11.61, p = 0.002). Further analysis showed that this difference may be related to the choice of treatment methods. Benefit was conferred to the APBI group for the outcome of non-breast cancer deaths. There was no significant difference between the two groups in terms of nodal recurrence, systemic recurrence, overall survival, or mortality rates. Toxicity side effects and cosmetic effects were similar in both groups, but intraoperative radiotherapy seemed to have a greater acute response. Material and methods: Searches for relevant randomized controlled trials of APBI versus WBI were performed using the following sources: PubMed, EMBASE, Cochrane Library, Web of Science. Two independent observers evaluated the identified studies. The meta-analysis was conducted using RevMan 5.2 software. Conclusions: Although the analysis showed that patients receiving APBI had a higher local recurrence rate, subgroup analyses suggested that this might be related to treatment options. Patients who receive accurate radiotherapy may have greater benefits. APBI is a promising treatment technology and more phase III clinical trials are expected based on new treatments.

Studies have demonstrated correlations between accumulations of tumour-associated macrophages (TAMs), especially of M2-like phenotype, and increased mortality in advanced breast cancer. We investigated the prognostic potential of both main macrophage phenotypes in early hormone receptor-positive (HR+) breast cancer. The studied cohort of 136 patients participated in an institutional APBI phase II trial. Patient selection was characterized by HR+, small tumour size and no metastasis. Tissue microarrays from pre-RT resection samples were double stained for CD68/CD163 using immunohistochemistry. CD68+/CD163&minus, cells were considered M1-like macrophages and CD68+/CD163+ was representative of M2-like macrophages. M1 and M2 macrophage densities were analysed semi-automatically in the stromal and intraepithelial tumour compartment. Low M1 and high M2 densities were strongly associated with decreased disease-free survival (DFS). Combined TAM phenotype densities were studied after defining a macrophage shift classification: M1-shifted (M1 high, M2 low) and non-shifted (M1 low, M2 low, M1 high, M2 high) tumours entailed a favourable outcome. In contrast, M2-shifted (M1 low, M2 high) TAM populations were associated with extremely reduced DFS. Thus, the full predictive potential of TAMs was revealed in a combined analysis of both phenotypes. The M2-shifted subgroup of tumours is classified as high-risk and probably not suitable for partial breast irradiation.

Background To update the clinical outcome of an elderly women cohort with early breast cancer who underwent accelerated partial breast irradiation (APBI) based on a post-operative single fraction of multicatheter interstitial high dose–rate brachytherapy (MIB). Material and methods A single institution retrospective cohort study was performed focusing on elderly patients (≥ 65 years old) presenting a low-risk breast carcinoma treated by lumpectomy plus axillary evaluation followed by MIB APBI. A single fraction of 16 Gy was prescribed on the 100% isodose. Clinical outcome at 5 years was reported based on local relapse free survival (LRFS), specific survival (SS) and overall survival (OS). Late toxicity was evaluated. Cosmetic results were evaluated clinically by the physician. Results Between January 2012 and August 2015, 48 women (51 lesions) were treated. Median age was 77.7 years (range: 65–92) with a median tumor size of 12 mm (range: 3–32). Five patients (pts) presented an axillary lymph node involvement (4 Nmic, 1 N1). Invasive ductal carcinoma was the most frequent histology type (86.3%). With a median follow–up of 64 months (range: 56–71), no local relapse occurred while 1 pt. developed an axillary relapse (2.1%). No Grade 3 or higher late toxicity was observed while 16 late toxicities occurred (G1: 14 events [87.5%) mainly G1 breast fibrosis). The rate of excellent cosmetic outcome was 76.4%. Conclusion We confirmed the safety of the process and remained encouraging clinical outcome of a post-operative single fraction of MIB ABPI in the elderly. This approach leads to consider a very APBI as an attractive alternative to intra-operative radiation therapy while all the patients will be good candidates for APBI in regards to the post-operative pathological report.

Purpose: Accelerated partial breast irradiation (A-PBI) in Korean women has been considered impracticable, owing to small breast volume and lack of high-precision radiotherapy experience. We present the first experience of stereotactic-PBI (S-PBI) with CyberKnife M6 to investigate feasibility of use and early toxicities in Korean women with early breast cancers. Materials and Methods: A total of 104 breasts receiving S-PBI at our institution between September 2017 and October 2018 were reviewed. Patients were selected based on the American Society for Radiation Oncology (ASTRO), American Brachytherapy Society, American Society of Breast Surgeons, and Groupe Europeen de Curietherapie-European Society for Therapeutic Radiology and Oncology guidelines. A dose of 30 Gy in 5 fractions (NCT01162200) was used. Gold fiducials were routinely inserted near the tumor bed for tracking. Constraints regarding organs-at-risk followed the NSABP-B39/RTOG 0413 protocol. Results: Median follow-up was for 13 months. Patients were categorized as "suitable" (71.2%) or "cautionary" (28.8%) according to 2017 the ASTRO guidelines. No tracking failure of inserted gold fiducials occurred. Median planning target volume (PTV) and PTV-to-whole breast volume ratio was 73.6 mL (interquartile range, 58.8-103.9 mL) and 17.0% (13.3-19.1%), respectively. Median PTV V95%, PTV Dmax, and ipsilateral breast V50% were 97.8% (96.2-98.8%), 105.3% (104.2-106.4%), and 35.5% (28.3-39.8%), respectively. No immediate post-S-PBI toxicity ≥ grade 2 was reported, except grade 2 induration in three breasts. All patients remain disease-free to date. Conclusion: The first use of S-PBI in Korean women was feasible and safe for selected early breast cancer. Based on these results, we have initiated a prospective study (NCT03568981) to test S-PBI in whole-breast irradiation for low-risk early breast cancer.

Introduction Mastectomy is the current standard of care for ipsilateral breast tumor recurrences after prior whole breast irradiation (WBI). We report our single-institution experience with breast-conserving surgery (BCS) followed by intraoperative radiotherapy (IORT) as an alternative to salvage mastectomy for new or recurrent breast cancers that develop in the setting of prior thoracic radiation. Methods We performed an IRB-approved retrospective review of patients treated with breast IORT between September 2013 and November 2016. We identified 12 patients who declined salvage mastectomy for their breast cancer after prior thoracic radiation. IORT was delivered using the Intrabeam™ device (Carl Zeiss, Germany). A dose of 20 Gy was prescribed to the lumpectomy cavity surface using 50 kV X-rays. We graded both acute and late treatment-related breast toxicities using the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Local control, mastectomy-free survival, distant metastasis, and overall survival were determined. Results Our study included nine patients who developed a new or recurrent ipsilateral breast cancer after prior WBI for early-stage breast cancer, two patients with primary breast cancer after mantle-field radiation for Hodgkin’s lymphoma, and one patient with a synchronous stage III non-small cell lung cancer treated with definitive radiation to the ipsilateral lung and mediastinum. The median time from prior radiation to presentation was 18 years (range: 2 months to 46 years). All patients successfully underwent partial breast reirradiation with IORT and were able to preserve their breast. At a median follow-up of 14 months (4–25 months), there were no local or distant recurrences. There was a single non-cancer-related death. In the acute setting, we observed grade 1 toxicity in 58% (n = 7), grade 2 toxicity in 17% (n = 2), and no grade 3 or higher toxicity. In the late setting, at least 3 months after IORT, we observed grade 1 hyperpigmentation and/or fibrosis in 50% (n = 6), symptomatic seroma requiring drainage in 33% (n = 4). A single patient developed an abscess requiring hospitalization and intravenous antibiotic therapy. Conclusion BCS with IORT is a feasible salvage option for patients who present with localized breast cancer after prior thoracic radiation treatment. Continued follow-up of these patients is warranted given the incidence of delayed toxicity.

The aim of this study was to report 3-year outcomes of toxicity, cosmesis, and local control using a once daily fractionation scheme (49.95 Gy in 3.33 Gy once daily fractions) for accelerated partial breast irradiation (APBI) using three-dimensional conformal radiotherapy (3D-CRT). Between July 2008 and August 2010, women aged ≥40 years with ductal carcinoma in situ or node-negative invasive breast cancer ≤3 cm in diameter, treated with breast-conserving surgery achieving negative margins, were accrued to a prospective study. Women were treated with APBI using 3-5 photon beams, delivering 49.95 Gy over 15 once daily fractions over 3 weeks. Patients were assessed for toxicities, cosmesis, and local control rates before APBI and at specified time points. Thirty-four patients (mean age 60 years) with Tis 0 (n = 9) and T1N0 (n = 25) breast cancer were treated and followed up for an average of 39 months. Only 3% (1/34) patients experienced a grade 3 subcutaneous fibrosis and breast edema and 97% of the patients had good/excellent cosmetic outcome at 3 years. The 3-year rate of ipsilateral breast tumor recurrence (IBTR) was 0% while the rate of contralateral breast events was 6%. The 3-year disease-free survival (DFS), overall survival (OS), and breast cancer-specific survival (BCSS) was 94%, 100%, and 100%, respectively. Our novel accelerated partial breast fractionation scheme of 15 once daily fractions of 3.33 Gy (49.95 Gy total) is a remarkably well-tolerated regimen of 3D-CRT-based APBI. A larger cohort of patients is needed to further ascertain the toxicity of this accelerated partial breast regimen.

Background and purpose To report the long-term results of a single-institution randomized study comparing the results of breast-conserving treatment with partial breast irradiation (PBI) or conventional whole breast irradiation (WBI). Patients and methods Between 1998 and 2004, 258 selected women with pT1 pN0-1mi M0, grade 1–2, non-lobular breast cancer without the presence of extensive intraductal component and resected with negative margins were randomized after BCS to receive 50Gy WBI ( n =130) or PBI ( n =128). The latter consisted of either 7×5.2Gy high-dose-rate (HDR) multi-catheter brachytherapy (BT; n =88) or 50Gy electron beam (EB) irradiation ( n =40). Primary endpoint was local recurrence (LR) as a first event. Secondary endpoints were overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and cosmetic results. Results After a median follow up of 10.2years, the ten-year actuarial rate of LR was 5.9% and 5.1% in PBI and WBI arms, respectively ( p =0.77). There was no significant difference in the ten-year probability of OS (80% vs 82%), CSS (94% vs 92%), and DFS (85% vs 84%), either. The rate of excellent-good cosmetic result was 81% in the PBI, and 63% in the control group ( p Conclusions Partial breast irradiation delivered by interstitial HDR BT or EB for a selected group of early-stage breast cancer patients produces similar ten-year results to those achieved with conventional WBI. Significantly better cosmetic outcome can be achieved with HDR BT implants compared with the outcome after WBI.

In recent years, accelerated partial breast irradiation (APBI) has been considered an alternative to whole breast irradiation for patients undergoing breast-conserving therapy. APBI delivers higher doses of radiation in fewer fractions to the post-lumpectomy tumor bed with a 1–2cm margin, targeting the area at the highest risk of local recurrence while sparing normal breast tissue. However, there are inherent challenges in defining accurate target volumes for APBI. Studies have shown that significant interobserver variation exists among radiation oncologists defining the lumpectomy cavity, which raises the question of how to improve the accuracy and consistency in the delineation of tumor bed volumes. The combination of standardized guidelines and surgical clips significantly improves an observer’s ability in delineation, and it is the standard in multiple ongoing external-beam APBI trials. However, questions about the accuracy of the clips to mark the lumpectomy cavity remain, as clips only define a few points at the margin of the cavity. This paper reviews the techniques that have been developed so far to improve target delineation in APBI delivered by conformal external beam radiation therapy, including the use of standardized guidelines, surgical clips or fiducial markers, pre-operative computed tomography imaging, and additional imaging modalities, including magnetic resonance imaging, ultrasound imaging, and positron emission tomography/computed tomography. Alternatives to post-operative APBI, future directions, and clinical recommendations were also discussed.

This prospective Phase II single-arm study gathered data on the use of intensity-modulated radiotherapy (IMRT) to deliver accelerated partial breast irradiation (APBI). Four-year efficacy, cosmesis, and toxicity results are presented. Between February 2004 and September 2007, 136 consecutive patients with Stage 0/I breast cancer and negative margins ≥0.2 cm were treated on protocol. Patients received 38.5 Gy in 10 equal fractions delivered twice daily. Breast pain and cosmesis were rated by patient, and cosmesis was additionally evaluated by physician per Radiation Therapy Oncology Group (RTOG) criteria. The National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE v3.0) was used to grade toxicities. 136 patients (140 breasts) with median follow-up of 53.1 months (range, 8.9–83.2) were evaluated. Population characteristics included median age of 61.9 years and Tis (13.6 %), T1a (18.6 %), T1b (36.4 %), and T1c (31.4 %). Kaplan–Meier estimates at 4 years: ipsilateral breast tumor recurrence 0.7 %; contralateral breast failure 0 %; distant failure 0.9 %; overall survival 96.8 %; and cancer-specific survival 100 %. At last follow-up, patients and physicians rated cosmesis as excellent/good in 88.2 and 90.5 %, respectively; patients rated breast pain as none/mild in 97.0 %. Other observations included edema (1.4 %), telangiectasia (3.6 %), five cases of grade 1 radiation recall (3.6 %), and two cases of rib fractures (1.4 %). This analysis represents the largest cohort and longest follow-up of APBI utilizing IMRT reported to date. Four-year results continue to demonstrate excellent local control, survival, cosmetic results, and toxicity profile.

This study includes four years of our clinical trials to improve implant quality in multicatheter accelerated partial breast irradiation (APBI). The progress in dosimetric and volumetric parameters of the treatment plans was evaluated. One hundred and ninety-one women, for whom treatment plans were made based on three dimensional imaging, were selected for the study. To evaluate progress made in our APBI procedure, following parameters and indices were taken into account: percentage of the target volume receiving the reference dose (PTVref), minimum dose in the target volume expressed as a percentage of reference dose (PTVmin), dose homogeneity index (DHI), and conformity index (COIN). Additionally, the plan quality index was calculated for every group as the sum of mean values of four evaluated parameters. PTVref have increased from the mean value of 83.4% at the beginning to recent 94.8%. The maximum value equals to 95.4%. The same trend can be observed with PTVmin value, which has been improved from 51.7% to 70.1%, maximally. DHI and COIN mean values present similar progress. DHI value increased from 0.53 level to 0.68, and COIN from 0.58 in 2009 to 0.74. Plan quality index has increased from 2.46 in 2009 to 3.06, recently. The implant quality is crucial for the accurate dose distribution. This paper shows the progress that was made in APBI procedure to improve implant quality. Nowadays, our implant technique is based on three-dimensional CT imaging results in acceptable dose distributions.

Accelerated partial breast irradiation (APBI) focuses higher doses of radiation during a shorter interval to the lumpectomy cavity, in the setting of breast conserving therapy for early stage breast cancer. The utilization of APBI has increased in the past decade because of the shorter treatment schedule and a growing body of outcome data showing positive cosmetic outcomes and high local control rates in selected patients undergoing breast conserving therapy. Technological advances in various APBI modalities, including intracavitary and interstitial brachytherapy, intraoperative radiation therapy, and external beam radiation therapy, have made APBI more accessible in the community. Results of early APBI trials served as the basis for the current consensus guidelines, and multiple prospective randomized clinical trials are currently ongoing. The pending long term results of these trials will help us identify optimal candidates that can benefit from ABPI. Here we provide an overview of the clinical and cosmetic outcomes of various APBI techniques and review the current guidelines for selecting suitable breast cancer patients. We also discuss the impact of APBI on the economics of cancer care and patient reported quality of life.

Background We report the results of a single-institution, phase II trial of accelerated partial breast irradiation (APBI) using a single dose of intraoperative electron radiation therapy (IOERT) in patients with low-risk early stage breast cancer. Methods and Materials A cohort of 226 patients with low-risk, early stage breast cancer were treated with local excision and axillary management (sentinel node biopsy with or without axillary node dissection). After the surgeon temporarily reapproximated the excision cavity, a dose of 21 Gy using IOERT was delivered to the tumor bed, with a margin of 2 cm laterally. Results With a mean follow-up of 46 months (range, 28-63 months), only 1 case of local recurrence was reported. The observed toxicity was considered acceptable. Conclusions APBI using a single dose of IOERT can be delivered safely in women with early, low-risk breast cancer in carefully selected patients. A longer follow-up is needed to ascertain its efficacy compared to that of the current standard treatment of whole-breast irradiation.

Whole breast irradiation represents an integral part of combined breast-conserving treatment of early breast cancer. A new concept includes replacing traditionally fractionated whole breast postoperative radiotherapy by accelerated partial breast irradiation. The latter involves a variety of techniques and may be applied intraoperatively or shortly after the surgery. The intraoperative techniques include photon or electron external beam irradiation and interstitial high dose rate (HDR) brachytherapy, whereas the postoperative techniques comprise interstitial brachytherapy, be it HDR, pulse dose rate (PDR) or low dose rate (LDR), intracavitary brachytherapy and external beam radiotherapy using electrons, photons or protons. This article presents accelerated partial breast irradiation techniques, ongoing phase III trials evaluating their value and recommendations for clinical practice.

The objective of this study has been to compare treatment plans for patients treated with electronic brachytherapy (eBx) using the Axxent System as adjuvant therapy for early stage breast cancer with treatment plans prepared from the same CT image sets using an Ir‐192 source. Patients were implanted with an appropriately sized Axxent balloon applicator based on tumor cavity size and shape. A CT image of the implanted balloon was utilized for developing both eBx and Ir‐192 brachytherapy treatment plans. The prescription dose was 3.4 Gy per fraction for 10 fractions to be delivered to 1 cm beyond the balloon surface. Iridium plans were provided by the sites on 35 of the 44 patients enrolled in the study. The planning target volume coverage was very similar when comparing sources for each patient as well as between patients. There were no statistical differences in mean %V100. The percent of the planning target volume in the high dose region was increased with eBx as compared with Iridium (p

Purpose To evaluate with a randomized clinical trial the possibility of treating the index quadrant with external intensity-modulated radiotherapy (IMRT) in a selected group of patients with early-stage breast cancer and to analyze the acute toxicity. Methods and Materials From September 2005, a randomized Phase III clinical trial has been conducted to compare conventional (tangential field) fractionated whole breast treatment (Arm A) with accelerated partial breast irradiation plus intensity-modulated radiotherapy (Arm B). For intensity-modulated radiotherapy, the clinical target volume was drawn with a uniform 1-cm margin around the surgical clips in three dimensions. The ipsilateral and contralateral breast, ipsilateral and contralateral lung, heart, and spinal cord were contoured as organs at risk. All the regions of interest were contoured according to the International Commission on Radiation Units and Measurements reports 50 and 62 recommendations. Results In September 2008, 259 patients were randomized and treated. The mean clinical target volume in Arm B was 44 cm 3 and the mean planning target volume was 123 cm 3 . The mean value of the ratio between the planning target volume and the ipsilateral breast volume was 21%. The rate of Grade 1 and Grade 2 acute skin toxicity was 22% and 19% in Arm A (Radiation Therapy Oncology Group scale), respectively. The tolerance in Arm B was excellent with only 5% Grade 1 and 0.8% Grade 2 acute skin toxicity. The planning constraints were fully satisfied in most patients. In a very few cases, this was not possible because of very unfavorable anatomy. Quality assurance procedures were performed according to our internal quality assurance protocol, with excellent results. Conclusion In the present preliminary analysis, we have demonstrated that accelerated partial breast irradiation is feasible, with very low acute toxicity.

The management of localized breast cancer has changed dramatically over the past three to four decades. Breast-conserving therapy, which involved lumpectomy followed by adjuvant irradiation, is now widely considered the standard of care in women with early-stage breast cancer. Accelerated partial breast irradiation (APBI), which involves focal irradiation of the lumpectomy cavity over a short period of time, has developed over the past two decades as an alternative to whole breast irradiation (WBI). Multiple APBI modalities have been developed including brachytherapy, external beam irradiation, and intraoperative irradiation. These new techniques have provided early-stage breast cancer patients with shorter treatment duration and more focused irradiation, delivering very high biological doses to the region at a high risk of failures over a much shorter treatment course as compared with conventional radiotherapy. However, the advantages of APBI over conventional radiotherapy are controversial, including a higher risk of complications reported in retrospective literature and shorter follow-up duration in the intraoperative APBI trials. Nevertheless, APBI presents a valuable alternative to WBI for a selected population of women with early-stage breast cancer.

Background Accelerated partial breast irradiation (APBI) is a new breast treatment modality aiming to reduce treatment time using hypo fractionation. Compared to conventional whole breast irradiation that takes 5 to 6 weeks, APBI is reported to induce worse cosmetic outcomes both when using three-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT). These late normal tissue effects may be attributed to the dose volume effect because a large portion of the non-target breast tissue volume (NTBTV) receives a high dose. In the context of APBI, non-coplanar beams could spare the NTBTV more efficiently. This study evaluates the dosimetric benefit of using the Cyberknife (CK) for APBI in comparison to IMRT (Tomotherapy) and three dimensional conformal radiotherapy (3D-CRT). Methods The possibility of using surgical clips, implanted during surgery, to track target movements is investigated first. A phantom of a female thorax was designed in-house using the measurements of 20 patients. Surgical clips of different sizes were inserted inside the breast. A treatment plan was delivered to the mobile and immobile phantom. The motion compensation accuracy was evaluated using three radiochromic films inserted inside the breast. Three dimensional conformal radiotherapy (3D-CRT), Tomotherapy (TOMO) and CK treatment plans were calculated for 10 consecutive patients who received APBI in Lille. To ensure a fair comparison of the three techniques, margins applied to the CTV were set to 10 mm. However, a second CK plan was prepared using 3 mm margins to evaluate the benefits of motion compensation. Results Only the larger clips (VITALITEC Medium-Large) could be tracked inside the larger breast (all gamma indices below 1 for 1 % of the maximum dose and 1 mm). All techniques meet the guidelines defined in the NSABP/RTOG and SHARE protocols. As the applied dose volume constraints are very strong, insignificant dosimetric differences exist between techniques regarding the PTV coverage and the sparing of the lung and heart. However, the CK may be used to reduce high doses received by the NTBTV more efficiently. Conclusions Robotic stereotactic radiotherapy may be used for APBI to more efficiently spare the NTBTV and improve cosmetic results of APBI.

Objectives(a) To prospectively determine if multidwell position dose delivery can decrease skin dose and resultant toxicity over single dwell balloon-catheter partial breast irradiation, and (b) to evaluate whether specific skin parameters could be safely used instead of skin-balloon distance alone for predicting toxicity and treatment eligibility.MethodsA single-arm phase II study using a Simon two-stage design was performed on 28 women with stage 0-II breast cancer. All patients were treated with multiple dwell position balloon-catheter brachytherapy. The primary endpoint was ≥ grade 2 skin toxicity. Initial entry required a balloon-skin distance ≥ 7 mm. Based on the toxicity in the first 16 patients, additional patients were treated irrespective of skin-balloon distance as long as the Dmax to 1 mm skin thickness was < 130%.ResultsCompared to the phantom single dwell plans, multidwell planning yielded superior PTV coverage as per median V90, V95 and V100, but had slightly worse V150, V200 and DHI. Dmax to skin was decreased by multidwell planning at multiple skin thicknesses. The most common acute toxicity was grade 1 erythema (57%), and only two patients (7%) developed acute grade 2 toxicity (erythema). Late grade 1 fibrosis was seen in 32%. No patients experienced grade 3, 4, or 5 toxicity.ConclusionsMultidwell position planning for balloon-catheter brachytherapy results in lower skin doses with equal to superior PTV coverage and an overall low rate of initial skin toxicity. Our data suggest that limiting the Dmax to < 130% to 1 mm thick skin is achievable and results in minimal toxicity.

In this Research Topic, Goyal and Haffty have collected a series of papers on the emerging field of cardio-oncology. Indeed, Darby et al.’s paper demonstrating an incremental 7% increase in risk of ischemic events per gray increase in mean heart dose has been a watershed moment in our efforts to improve the therapeutic ratio of adjuvant breast radiotherapy (1). While a 0.07 increase over baseline risk per Sievert may seem high, it is important to understand this relative increase in risk in the context of the absolute baseline risk. Darby and colleagues do not provide a denominator for eligible patients in the two population registries from which they drew their cases and controls. Instead, they estimate the baseline risk using data from 15 Western European nations, and in Table S12 of the Supplementary Material, go on to estimate the absolute risk increase by age 80 years in women exposed to RT at various ages and with various co-morbid risk profiles. The excess absolute risks appear to be modest at first glance. For example, for a young 40-year-old woman receiving a high mean heart dose of 10 Gy, the estimated absolute excess risk of dying from cardiac disease is about 1.4%. Should the same woman have at least one co-morbid risk factor, her excess risk is 2.3%. These numbers may seem small, but are certainly relevant at the population level, especially given that the mortality benefit of adjuvant radiotherapy is also modest (2). Current efforts at reducing the risks of incidental cardiac irradiation have included advanced radiotherapy techniques for cardiac avoidance such as breath hold (3), gating treatments (4), proton therapy (5), prone positioning (6), and combinations thereof such as respiratory gating in the prone position (7). Cardiac avoidance techniques are illustrative of the general potential that technological innovations can have on human health. Going back to the very development of megavoltage machines, improvements in radiation delivery have consistently improved the therapeutic ratio in any number of settings. Recent reports have demonstrated fewer late second malignancies in children treated with proton therapy (8), lower rates of desquamation in breast cancer patients treated with IMRT (9), higher rates of local control in lung cancer patients treated with SBRT (10), and improved biochemical control in patients treated with highly conformal, high-dose radiotherapy for prostate cancer (11). Similar improvements in image-guided gynecological brachytherapy (12), IMRT in head/neck (13), GI (14), and gynecological malignancies (15), as well as intracranial SRS (16) have all demonstrated better outcomes compared with control data. Even as the calls for controlling costs become ever more constant, it is important to remember that the current excitement for a genomically driven model of cancer care has become possible only because of technological improvements in sequencing technologies. As such, continued funding, both federal and private, for technology innovations is critical and should not be relegated to lower tiers of priority. Coming back to breast cancer patients and the cardiac risks they face from radiotherapy, one additional (seemingly obvious) point needs to be made. While we can invoke continually advancing technologies for the purposes of cardiac avoidance (17), sometimes a return to simpler solutions may be all that is needed. Many women with early-stage breast cancer are eligible for off-protocol accelerated partial breast irradiation as a standard of care option (18). As one would expect, irradiating a smaller volume of breast tissue leads to lower incidental heart doses (19). Current studies and protocols examining, for example, breath hold parameters or prone positioning often include a large contingent of women who are candidates for partial breast irradiation. One rather elegant way to avoid treating the heart is to simply not treat it.

After breast conserving surgery, early stage breast cancer patients are currently treated with a wide range of radiation techniques including whole breast irradiation (WBI), accelerated partial breast irradiation (APBI) using high dose rate (HDR) brachytherapy, or 3D conformal radiotherapy (3D-CRT). This study compares the mean heart’s doses for a left breast irradiated with different breast techniques. An anthropomorphic Rando phantom was modified with gelatin-based breast of different sizes and tumors located medially or laterally. The breasts were treated with WBI, 3D-CRT or HDR APBI. The heart’s mean doses were measured with Gafchromic films and controlled with optically stimulated luminescent dosimeters (OSLDs). Following the model reported by Darby (16), major cardiac were estimated assuming a linear risk increase with the mean dose to the heart of 7.4% per gray. Whole breast irradiation lead to the highest mean heart dose (2.99 Gy) compared to 3D-CRT APBI, (0.51 Gy), multicatheter (1.58 Gy) and balloon HDR (2.17 Gy) for a medially located tumor. This translated into long-term coronary event increases of 22%, 3.8%, 11.7%, and 16% respectively. The sensitivity analysis showed that the tumor location had almost no effect on the mean heart dose for 3D-CRT APBI and a minimal impact for HDR APBI. For WBI large breast size and set-up errors lead to sharp increases of the mean heart dose. Its value reached 10.79 Gy for women with large breast and a set-up error of 1.5 cm. Such a high value could increase the risk of having long-term coronary events by 80%. Comparison among different irradiation techniques demonstrates that 3D-CRT APBI appears the safest one with less probability of having cardiovascular events in the future. A sensitivity analysis showed that WBI is the most challenging technique for patients with large breasts or when significant set-up errors are anticipated. In those cases additional heart shielding techniques are required.

Purpose: To report outcomes in breast cancer patients with prior breast augmentation treated with external beam accelerated partial breast irradiation (EB-APBI) utilizing intensity modulated radiotherapy (IMRT) or 3-dimensional conformal radiotherapy (3D-CRT), both with image-guided radiotherapy (IGRT).Methods and Materials: 16 stage 0/I breast cancer patients with previous elective bilateral augmentation were treated post-lumpectomy on institutional EB-APBI trials (01185132 and 01185145 on clinicaltrials.gov). Patients received 38.5 Gy in 10 fractions over 5 consecutive days. Breast/chest wall pain and cosmesis were rated by patient; cosmesis was additionally evaluated by physician per RTOG criteria.Results: The median follow-up from APBI completion was 18.0 months (range, 1.2-58.6). Little to no change in cosmesis or pain from baseline was reported. Cosmetic outcomes at last follow-up were judged by patients as excellent/good in 93.8% (15/16), and by physicians as excellent/good in 100% (16/16). Eight patients (50.0%) reported no breast/chest wall pain, and the remaining 8 patients (50.0%) reported mild pain. All patients remain disease free at last follow-up. The median ipsilateral breast, planning target volume (PTV), and implant volumes were 614 cc, 57 cc, and 333 cc. The median ratios of PTV/ipsilateral breast volume (implant excluded) and PTV/total volume (implant included) were 9% and 6%. Conclusions: These 16 breast cancer cases with prior bilateral breast augmentation treated with external beam APBI demonstrate favorable clinical outcomes. Further exploration of external beam APBI as a treatment option for this patient po

Purpose To describe a breast-conserving technique using interstitial brachytherapy after lumpectomy and axillary nodal sampling in selected women who are diagnosed with breast cancer in the presence of augmentation mammoplasty. Material and methods Over the past 20 years, we have developed and improved a technique of “pinch view” image-guided catheter insertion that avoids implant puncture. Selection criteria include: 1) women of any age with either subpectoral or retroglandular, augmentation implants (silicone or saline) who were diagnosed with stages Tis, T1, T2, N0, or N1 breast cancer; 2) any pathologic subtype of malignant breast cancer was accepted; 3) microscopic tumor extent ≤ 3 cm; 4) axillary node negative or metastasis to 1 to 3 nodes without extracapsular extension; and 5) surgical margins clear by the NSABP “no ink on tumor” definition. More than 250 women have been successfully treated. Patients were treated with high dose rate Iridium-192 brachytherapy to 34 Gy in 10 or 32 Gy in 8 twice daily fractions. The target volume was the surgical cavity edge with 1.5 to 2 cm margin using 3-D treatment planning systems. Results The implant technique as currently employed is described. There have been no implant ruptures, and the Planning Treatment Volume (PTV-eval) exhibited at least 90% coverage by the 90% isodose line in the vast majority of cases. Dose Homogeneity Index exceeded 70% in most cases. The maximum skin dose was below the prescription dose in every case. Other than some patients with pre-existing capsular contracture, less than 5% experience new capsular contracture after interstitial brachytherapy. Conclusions A technique of reliable and reproducible accelerated partial breast irradiation is described that minimizes the risk of capsular contracture by avoiding circumferential dose to the foreign body in the breast.

Background Radiation induced secondary cancers are a rare but severe late effect after breast conserving therapy. Intraoperative radiotherapy (IORT) is increasingly used during breast conserving surgery. The purpose of this analysis was to estimate secondary cancer risks after IORT compared to other modalities of breast radiotherapy (APBI - accelerated partial breast irradiation, EBRT - external beam radiotherapy). Methods Computer-tomography scans of an anthropomorphic phantom were acquired with an INTRABEAM IORT applicator (diameter 4 cm) in the outer quadrant of the breast and transferred via DICOM to the treatment planning system. Ipsilateral breast, contralateral breast, ipsilateral lung, contralateral lung, spine and heart were contoured. An INTRABEAM source (50 kV) was defined with the tip of the drift tube at the center of the spherical applicator. A dose of 20 Gy at 0 mm depth from the applicator surface was prescribed for IORT and 34 Gy (5 days × 2 × 3.4 Gy) at 10 mm depth for APBI. For EBRT a total dose of 50 Gy in 2 Gy fractions was planned using two tangential fields with wedges. The mean and maximal doses, DVHs and volumes receiving more than 0.1 Gy and 4 Gy of organs at risk (OAR) were calculated and compared. The life time risk for secondary cancers was estimated according to NCRP report 116. Results IORT delivered the lowest maximal doses to contralateral breast (< 0.3 Gy), ipsilateral (1.8 Gy) and contralateral lung (< 0.3 Gy), heart (1 Gy) and spine (< 0.3 Gy). In comparison, maximal doses for APBI were 2-5 times higher. EBRT delivered a maximal dose of 10.4 Gy to the contralateral breast and 53 Gy to the ipsilateral lung. OAR volumes receiving more than 4 Gy were 0% for IORT, < 2% for APBI and up to 10% for EBRT (ipsilateral lung). The estimated risk for secondary cancer in the respective OAR is considerably lower after IORT and/or APBI as compared to EBRT. Conclusions The calculations for maximal doses and volumes of OAR suggest that the risk of secondary cancer induction after IORT is lower than compared to APBI and EBRT.

Accelerated partial breast irradiation (APBI) with high dose rate (HDR) brachytherapy offers an excellent compact course of radiation due to its limited number of fractions for early-stage carcinoma of breast. One of the recent devices is SAVI (strut-adjusted volume implant), which has 6, 8 or 10 peripheral source channels with one center channel. Each channel can be differentially loaded. This paper focuses on the treatment planning, dosimetry and quality assurance aspects of HDR brachytherapy implant with GammaMed Plus HDR afterloader unit. The accelerated PBI balloon devices normally inflate above 35 cc range, and hence these balloon type devices cannot be accommodated in small lumpectomy cavity sizes. CT images were obtained and 3-D dosimetric plans were done with Brachyvision planning system. The 3-D treatment planning and dosimetric data were evaluated with planning target volume (PTV)_eval V90, V95, V150, V200 skin dose and minimum distance to skin. With the use of the SAVI 6-1 mini device, we were able to accomplish an excellent coverage - V90, V95, V150 and V200 to 98%, 95%, 37 cc (

In this study, we evaluate the attenuation of the dose due to barium‐impregnation in the region between the surface of an electronic brachytherapy (EBT) balloon applicator for accelerated partial breast irradiation (APBI) and the prescription point at 1 cm depth in tissue. To perform the study, depth dose curves were calculated using a general purpose multi‐particle transport code (FLUKA) for a range of balloon wall thicknesses with and without barium impregnation. Numerical data were verified with experimental readings using a parallel plate extrapolation ionization chamber for different wall thicknesses. Depth dose curves computed using both numerical and experimental methods show a 6.0% attenuation of the dose at the 1.0 cm prescription line due to the impregnation of barium in the balloon material, which agrees well with the manufacturer's specification. By applying this single attenuation factor, dose calculations throughout the entire planned volume are uniformly affected. However, at the balloon surface, attenuation on the order of 18.0% is observed. The AAPM TG‐43 source data currently incorporated in commercially‐available treatment planning systems do not account for the variable dose distributions attributable to balloon wall attenuation. Our results show that variable attenuation factors that may have clinical significance should be applied in order to determine near‐surface dose distributions when using barium impregnated balloons for intracavitary breast brachytherapy. Dose distributions at distances greater than 1 cm from the surface of the balloon appear to be accurately represented without further modification. PACS numbers: 87.53.Jw, 87.55.D‐, 87.55.d, 87.55.Qr, 87.55.K‐

Background: The MammoSite radiotherapy system is an alternative treatment option for patients with early-stage breast cancer to overcome the longer schedules associated with external beam radiation therapy. The device is placed inside the breast surgical cavity and inflated with a combination of saline and radiographic contrast to completely fill the cavity. The treatment schedule for the MammoSite monotherapy is 34 Gy delivered in 10 fractions at 1.0 cm from the balloon surface with a minimum of 6 hours between fractions on the same day. Material and methods: This review article presents the advantages, disadvantages, uncertainties and clinical outcomes associated with the MammoSite brachytherapy (MSB). Results. Potential advantages of MSB are: high localised dose with rapid falloff for normal tissue sparing, minimum delay between surgery and RT, catheter moves with breast, improved local control, no exposure to staff, likely side-effects reduction and potential cost/time saving (e.g. for country patients). The optimal cosmetic results depend on the balloon-to-skin distance. Good-to-excellent cosmetic results are achieved for patients with balloon-skin spacing of ≥7 mm. There have been very few published data regarding the long term tumour control and cosmesis associated with the MSB. The available data on the local control achieved with the MSB were comparable with other accelerated partial breast irradiation techniques. The contrast medium inside the balloon causes dose reduction at the prescription point. Current brachytherapy treatment planning systems (BTPS) do not take into account the increased photon attenuation due to high Z of contrast. Some BTPS predicted up to 10% higher dose near the balloon surface compared with Monte Carlo calculations using various contrast concentrations (5–25%). Conclusion: Initial clinical results have shown that the MammoSite device could be used as a sole radiation treatment for selected patients with early stage breast cancer providing good local control, minimal complication rate and excellent cosmesis. Refereed/Peer-reviewed

The development of new catheter and applicator technologies in recent years has significantly improved treatment accuracy, efficiency, and outcomes in brachytherapy. In this paper, we review these advances, focusing on the performance of catheter imaging and reconstruction techniques in brachytherapy procedures using magnetic resonance images and electromagnetic tracking. The accuracy of catheter reconstruction, imaging artifacts, and other notable properties of plastic and titanium applicators in gynecologic treatments are reviewed. The accuracy, noise performance, and limitations of electromagnetic tracking for catheter reconstruction are discussed. Several newly developed applicators for accelerated partial breast irradiation and gynecologic treatments are also reviewed. New hypofractionated high dose rate treatment schemes in prostate cancer and accelerated partial breast irradiation are presented.

Altered fractionation schedules are being increasingly investigated in the treatment of breast cancer. Two such schedules that are frequently compared are hypofractionated external beam radiation therapy (HERT) and accelerated partial breast irradiation (APBI). Though these two modalities are considered separately, APBI is an actually an advanced form of hypofractionation, where acceleration of the treatment is possible due to the smaller volume being irradiated. HERT as well as APBI are investigational at present and are being tested in randomized trials. This article looks at the advantages of APBI as a hypofractionation schedule.

Breast-conserving therapy (BCT) has emerged as a viable option for suitable breast cancer patients who are desirous of preserving the breast. The major advantage of BCT is the good cosmetic outcome with disease-free and overall survival similar to mastectomy. In this article, I have compared two emerging modalities for treating a preserved breast with radiotherapy. These two techniques in breast cancer - accelerated partial breast irradiation (APBI) and hypofractionated whole breast external beam radiotherapy - have their respective merits and drawbacks, and this article attempts to dissect the issue.