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Accelerated partial breast irradiation with high dose rate brachytherapy treats early-stage carcinoma. Strut-adjusted volume implant applicators are inserted into the cavity post-lumpectomy. For an unstable applicator, changes in distance are seen each day between struts. If an applicator is asymmetrical with no strut movement on subsequent days, then it is stable. If an asymmetrical applicator continues to change strut distances, it is unstable. Waiting for applicator stabilization improves treatment reproducibility but increases infection risk. There is currently no consensus on stability, with ranges from 24 hours (h) to 72 h. Therefore, this study aims to determine when stability is achieved. We retrospectively reviewed 242 female breast cancer patients (2014–2022). CT was performed the same day as applicator insertion (Day 0) and repeated each treatment day. If applicators were initially asymmetrical, the distance between adjacent struts was measured, and the percentage change between the next and previous treatment day was calculated to determine how many applicators stabilized. Less than 5% change indicated stability. On Day 0, 208 out of 242 patients (86%) had stable and symmetrical applicators that maintained stability each treatment day, and 34 out of 242 patients (14%) had applicators with asymmetrical struts. Within 24 h post-insertion, 229 out of 242 (95%) patients had stabilized applicators that maintained stability on subsequent treatment days. Narrows previously suggested stability (24–72 h) to 24 h, leading to improved treatment efficiency and decreased infection risk as less time is needed to achieve applicator stability. [ABSTRACT FROM AUTHOR]

Introduction: Intraoperative radiotherapy (IORT) with electrons has revealed to have higher rates of ipsilateral breast tumor recurrence (IBTR) than external beam radiotherapy in updated large-scale, randomized controlled trials in 2021. This study details the oncological outcomes of IORT with electron beams using our strict IORT policies. We have found new and important observations regarding the location of recurrence. Methods and materials: This is a single institution registry of early-stage breast cancer patients who underwent lumpectomy and electron beam IORT with appropriate cone size. All patients met our pre-excision requirements. The primary endpoint was 5-year IBTR rate, with secondary endpoints being 5-year locoregional failure rate, 5-year distant metastasis rate, 5-year overall survival and, importantly, the failure patterns. Results: Between January 2011 and December 2022, 124 patients were recruited. The median follow-up was 6.7 years. The 5-year IBTR rate was 1.87% (95% CI 0.47–7.29%), which is much lower than the ELIOT trial and comparable with other accelerated partial breast irradiation (APBI) techniques. The 5-year locoregional failure rate was 3.68% (95% CI 1.40–9.52%), and the 5-year distant metastasis rate was 0.88% (95% CI 0.13–6.12%), while the 5-year overall survival rate was 97.52% (95% CI 92.44–99.19%). Six patients experienced IBTR. All recurrences were in surgical area, occurring superficial to the tumor bed and within 1 cm of the skin dermis. This failure pattern is very unique and might be explained by our hypothesis of the non-irradiated area beneath the skin. Conclusions: IORT with electron beams with strict patient selection criteria and strict large cone size is still an acceptable treatment for select patients with early-stage breast cancer. However, our new findings support extreme caution in the non-irradiated area beneath the skin around the tumor cavity. Given the constraints of our sample size, these findings should be interpreted cautiously and warrant further investigation in larger, more comprehensive studies. [ABSTRACT FROM AUTHOR]

Abstract Background Accelerated partial breast irradiation (APBI) is an accepted treatment option for early breast cancer. Treatment delivered on the Magnetic Resonance integrated Linear Accelerator (MRL) provides the added assurance of improved soft tissue visibility, important in the delivery of APBI. This technique can be delivered in both the supine and prone positions, however current literature suggests that prone treatment on the MRL is infeasible due to physical limitations with bore size. This study aims to investigate the feasibility of positioning patients on a custom designed prone breast board compared with supine positioning on a personalised vacuum bag. Geometric distortion, the relative position of Organs at Risk (OAR) to the tumour bed and breathing motion (intrafraction motion) will be compared between the supine and prone positions. The study will also investigate the positional impact on dosimetry, patient experience, and position preference. Methods Up to 30 patients will be recruited over a 12-month period for participation in this Human Research Ethics Committee approved exploratory cohort study. Patients will be scanned on the magnetic resonance imaging (MRI) Simulator in both the supine and prone positions as per current standard of care for APBI simulation. Supine and prone positioning comparisons will all be assessed on de-identified MRI image pairs, acquired using appropriate software. Patient experience will be explored through completion of a short, anonymous electronic survey. Descriptive statistics will be used for reporting of results with categorical, parametric/non-parametric tests applied (data format dependent). Survey results will be interpreted by comparison of percentage frequencies across the Likert scales. Thematic content analysis will be used to interpret qualitative data from the open-ended survey questions. Discussion The results of this study will be used to assess the feasibility of treating patients with APBI in the prone position on a custom designed board on the MRL. It may also be used to assist with identification of patients who would benefit from this position over supine without the need to perform both scans. Patient experience and technical considerations will be utilised to develop a tool to assist in this process. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN1262400067583. Registered 28th of May 2024. https://www.anzctr.org.au/ACTRN12624000679583.aspx

Objective: Reports demonstrating the effectiveness and safety of strut-adjusted volume implants (SAVI) in Japan are limited. Therefore, this study aimed to compare the treatment outcomes of SAVI and whole-breast irradiation (WBI) at a single facility. Materials and Methods: Data were retrospectively extracted from the medical records of patients treated with SAVI or WBI following partial mastectomy (Bp). Patients undergoing Bp, sentinel lymph node biopsy, and SAVI spacer insertion followed by brachytherapy with the SAVI device were compared to those followed with WBI. Local recurrence was assessed annually by physical examination, bilateral mammography, and breast ultrasonography. Results: The SAVI and WBI groups comprised 53 and 113 patients, with a median age of 55 and 52 years, respectively; among them, 47 and 91 patients had a pathological tumor diameter ≤2 cm and six and 22 had a pathological tumor diameter >2 cm, respectively. Recurrence events, acute adverse events, and late adverse events were observed in the SAVI and WBI groups in 1 and 3 (p = 0.726), 24 and 79 (p = 0.01), and 24 and 18 patients (p = 0.00002), respectively, with median observation periods of 60.0 and 47.8 months, respectively. All adverse events were grades 1–2, with dermatitis being the most common in the acute phase. In the late phase, pigmentation was common in both groups. Conclusion: The local recurrence rate does not differ between SAVI and WBI within the relatively short-term follow-up period. Longer follow-up is required to confirm our results in the Japanese population.

Background: Accelerated partial breast irradiation (APBI) is an accepted treatment option for early breast cancer. Treatment delivered on the Magnetic Resonance integrated Linear Accelerator (MRL) provides the added assurance of improved soft tissue visibility, important in the delivery of APBI. This technique can be delivered in both the supine and prone positions, however current literature suggests that prone treatment on the MRL is infeasible due to physical limitations with bore size. This study aims to investigate the feasibility of positioning patients on a custom designed prone breast board compared with supine positioning on a personalised vacuum bag. Geometric distortion, the relative position of Organs at Risk (OAR) to the tumour bed and breathing motion (intrafraction motion) will be compared between the supine and prone positions. The study will also investigate the positional impact on dosimetry, patient experience, and position preference. Methods: Up to 30 patients will be recruited over a 12-month period for participation in this Human Research Ethics Committee approved exploratory cohort study. Patients will be scanned on the magnetic resonance imaging (MRI) Simulator in both the supine and prone positions as per current standard of care for APBI simulation. Supine and prone positioning comparisons will all be assessed on de-identified MRI image pairs, acquired using appropriate software. Patient experience will be explored through completion of a short, anonymous electronic survey. Descriptive statistics will be used for reporting of results with categorical, parametric/non-parametric tests applied (data format dependent). Survey results will be interpreted by comparison of percentage frequencies across the Likert scales. Thematic content analysis will be used to interpret qualitative data from the open-ended survey questions. Discussion: The results of this study will be used to assess the feasibility of treating patients with APBI in the prone position on a custom designed board on the MRL. It may also be used to assist with identification of patients who would benefit from this position over supine without the need to perform both scans. Patient experience and technical considerations will be utilised to develop a tool to assist in this process. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN1262400067583. Registered 28th of May 2024. https://www.anzctr.org.au/ACTRN12624000679583.aspx [ABSTRACT FROM AUTHOR]

Partial breast irradiations with electronic brachytherapy or kilovoltage intraoperative radiotherapy devices such as Axxent or INTRABEAM are becoming more common every day. Breast is mainly composed of glandular and adipose tissues, which are not always clearly disentangled in planning breast CTs. In these cases, breast tissues are replaced with an average soft tissue, or even water. However, at kilovoltage energies, this may lead to large differences in the delivered dose, due to the dominance of photoelectric effect. Therefore, the aim of this work was to study the effect on the dose prescribed in breast with the INTRABEAM device using different soft tissue assignment strategies that would replace the adipose and glandular tissues that constitute the breast in cases where these tissues cannot be adequately distinguished in a CT scan. Dose was computed with a Monte Carlo code in five patients with a 3 cm diameter INTRABEAM spherical applicator. Tissues within the breast were assigned following six different strategies: one based on the TG-43 recommendations, representing the whole breast as water of unity density, another one also water-based but with CT derived density, and the other four also based on CT-derived densities, using a single tissue resulting from different mixes of glandular and adipose tissues. These were compared against the reference dose computed in an accurately segmented CT, following TG-186 recommendations. Relative differences and dose ratios between the reference and the other tissue assignment strategies were obtained in three regions of interest inside the breast. Dose planning in water-based tissues was found inaccurate for breast treatment with INTRABEAM, as it would incur in up to 30% under-prescription of dose. If accurate soft tissue assignments in the breast cannot be safely done, a single-tissue composition of 80% adipose and 20% glandular tissue, or even a 100% adipose tissue, would be recommended to avoid dose under-prescription. [ABSTRACT FROM AUTHOR]

Objective: Reports demonstrating the effectiveness and safety of strut-adjusted volume implants (SAVI) in Japan are limited. Therefore, this study aimed to compare the treatment outcomes of SAVI and whole-breast irradiation (WBI) at a single facility. Materials and Methods: Data were retrospectively extracted from the medical records of patients treated with SAVI or WBI following partial mastectomy (Bp). Patients undergoing Bp, sentinel lymph node biopsy, and SAVI spacer insertion followed by brachytherapy with the SAVI device were compared to those followed with WBI. Local recurrence was assessed annually by physical examination, bilateral mammography, and breast ultrasonography. Results: The SAVI and WBI groups comprised 53 and 113 patients, with a median age of 55 and 52 years, respectively; among them, 47 and 91 patients had a pathological tumor diameter ≤2 cm and six and 22 had a pathological tumor diameter >2 cm, respectively. Recurrence events, acute adverse events, and late adverse events were observed in the SAVI and WBI groups in 1 and 3 (p = 0.726), 24 and 79 (p = 0.01), and 24 and 18 patients (p = 0.00002), respectively, with median observation periods of 60.0 and 47.8 months, respectively. All adverse events were grades 1-2, with dermatitis being the most common in the acute phase. In the late phase, pigmentation was common in both groups. Conclusion: The local recurrence rate does not differ between SAVI and WBI within the relatively short-term follow-up period. Longer follow-up is required to confirm our results in the Japanese population. [ABSTRACT FROM AUTHOR]

Introduction: We compared the dosimetric characteristics of the target and organs at risk (OARs) as well as the preliminary clinical outcomes between two accelerated partial breast irradiation (APBI) techniques. Methods: Forty-four patients diagnosed with left-sided early breast cancer who underwent APBI using either interstitial brachytherapy (IB) or stereotactic body radiation therapy (SBRT) with CyberKnife (CK) were retrospectively reviewed. The dosimetric parameters of the target and OARs were compared. Preliminary clinical outcomes, including tumor control and acute toxicity, were analyzed. Results: Treatment plans with CK demonstrated a better cardiac dose-sparing effect. Radiation doses to the heart at V150cGy for the CK and IB groups were 24.4 % and 60.4 %, respectively (p

Purpose: The aim of this study is to evaluate the cosmetic outcome among early stage breast cancer patients who underwent accelerated partial breast irradiation with either intraoperative electron radiotherapy (IOERT) or photon external beam radiotherapy (EB-APBI). Materials and methods: This prospective multicenter cohort study enrolled women aged 60 years and older who underwent breast-conserving therapy. Following breast-conserving surgery, patients were treated with either IOERT or EB-APBI. Cosmetic outcome was evaluated over a 5 year follow-up period using both subjective scoring by patients and physicians, as well as objective scoring using BCCT.core software. Differences between treatments over time were described with mixed model analyses. Results: A total of 241 patients treated with IOERT and 164 patients treated with EB-APBI were eligible for cosmetic analysis. In both groups, the majority of patients reported a satisfactory cosmetic outcome, with no significant differences between treatments over time (p = 0.538). This was also observed by physicians, with satisfactory outcomes ranging from 94 % (170/181) to 91 % (69/76) over time in the IOERT group and from 93 % (124/133) to 95 % (54/57) in the EB-APBI group (p = 0.579). BCCT.core analysis returned satisfactory cosmetic outcomes in 75 % (54/72) of the IOERT patients at 3 years and in 77 % (20/26) at 5 years. These numbers were 86 % (72/84) and 90 % (36/40) for the EB-APBI patients, with no significant differences between treatment over time (p = 0.834). Conclusion: Regarding the cosmetic results, IOERT and EB-APBI yield comparable and satisfactory outcomes over 5 years follow-up in the treatment of early stage breast cancer.

Background: In reconstructive surgery, local flaps might develop tissue necrosis or partial flap loss especially after previous irradiation, which may be necessary in many tumor entities. The application of stem cells seems promising to improve flap perfusion and might be a possible solution to optimize flap survival. Methods: Twenty rats received harvesting of bilateral random pattern fasciocutaneous flaps. The right flaps received 20 Gy ionizing radiation 4 weeks prior to the surgery, while the left flaps served as the non-irradiated control. After flap harvest, four different stem cell mixtures (5 × 106 ASC, ASC-HUVEC, MSC, MSC-HUVEC) were applied under both right and left flaps using 1 mL fibrin glue as the delivery vehicle. Flap size and its necrotic area were examined clinically. Two weeks after the surgery, HE staining and immunohistochemical staining for CD68 and ERG, as well as PCR analysis (Interleukin 6, HIF-1α and VEGF), were performed. Results: Application of ASCs, ASCs-HUVECs and MSCs resulted in a lower number of CD68-stained cells compared to the no cell group. The expression of Hif1α was higher in the ASC group compared to those in the MSC and previously treated no cell groups. Treatment with MSCs and MSCs-HUVECs prevented shrinking of the flaps in this series. Conclusion: Application of ASCs, MSCs and ASCs-HUVECs was shown to have an antiinflammatory effect. Treatment with MSCs and MSCs-HUVECs can prevent early shrinking of the flaps. [ABSTRACT FROM AUTHOR]

Women with left-sided breast cancer receiving adjuvant radiotherapy have increased incidence of cardiac mortality due to ischemic heart disease; to date, no threshold dose for late cardiac/pulmonary morbidity or mortality has been established. We investigated the likelihood of cardiac death and radiation pneumonitis in women with left-sided breast cancer who received comprehensive lymph node irradiation. The differences in dosimetric parameters between free-breathing (FB) and deep inspiration breath hold (DIBH) techniques were also addressed. Based on NTCP calculations, the probability of cardiac death was significantly reduced with the DIBH compared to the FB technique (p < 0.001). The risk of radiation pneumonitis was not clinically significant. There was no difference in coverage between FB and DIBH plans. Doses to healthy structures were significantly lower in DIBH plan than in FB plan for V20, V30, and ipsilateral total lung volume. Inspiratory gating reduces the dose absorbed by the heart without compromising the target range, thus reducing the likelihood of cardiac death. [ABSTRACT FROM AUTHOR]

Background: The effectiveness and safety of moderately hypofractionated radiotherapy (HFRT) in patients undergoing breast-conserving surgery (BCS) has been demonstrated in several pivotal randomized trials. However, the feasibility of applying simultaneous integrated boost (SIB) to the tumor bed and regional node irradiation (RNI) using modern radiotherapy techniques with HFRT needs further evaluation. Methods: This prospective, multi-center, randomized controlled, non-inferiority phase III trial aims to determine the non-inferiority of HFRT combined with SIB (HFRTsib) compared with conventional fractionated radiotherapy with sequential boost (CFRTseq) in terms of five-year locoregional control rate in breast cancer patients undergoing upfront BCS. A total of 2904 participants will be recruited and randomized in a 1:1 ratio into the HFRTsib and CFRTseq groups. All patients will receive whole breast irradiation, and those with positive axillary nodes will receive additional RNI, including internal mammary irradiation. The prescribed dose for the HFRTsib group will be 40 Gy in 15 fractions, combined with a SIB of 48 Gy in 15 fractions to the tumor bed. The CFRTseq group will receive 50 Gy in 25 fractions, with a sequential boost of 10 Gy in 5 fractions to the tumor bed. Discussion: This trial intends to assess the effectiveness and safety of SIB combined with HFRT in early breast cancer patients following BCS. The primary endpoint is locoregional control, and the results of this trial are expected to offer crucial evidence for utilizing HFRT in breast cancer patients after BCS. Trial registration: This trial was registered at ClincalTrials.gov (NCT04025164) on July 18, 2019. [ABSTRACT FROM AUTHOR]

The addition of a boost to the lumpectomy bed after whole-breast (WB) radiotherapy plays a key role in the treatment of patients with breast cancer (BC). The clinical benefits of a boost with high-dose-rate brachytherapy (HDR-BT) after conventional fractionation is supported by a large body of evidence. However, few studies have described its outcomes after a hypofractionated scheme. We included all patients treated with adjuvant WB-IMRT in 15 sessions followed by a single-session HDR-BT boost with local anesthesia on an outpatient basis. Between 2009 and 2017, 638 patients with early-stage BC were treated according to the aforementioned protocol after breast-conserving surgery. Median follow-up was 6 years (4–11). Despite the low incidence of side effects and their slightness, we did identify an impact of breast volume on the risk of acute radiodermatitis, fibrosis, pain and edema. However, we did not identify any relationship between the volume in cubic centimeters of the BT-implant with acute or long-term side effects. 2.2% patients had an actual local relapse, 2.4% a 2nd primary in the same breast and 2.39% were diagnosed with contralateral BC. Event-free survival at 11 years was 85.5% with an overall survival of 95.7%. Adjuvant hypofractionated whole-breast IMRT followed by a single dose HDR-BT boost has a low incidence of acute and chronic toxicity and excellent oncological outcomes. However, it may be worthwhile to intensify self-care protocols and surveillance in women with large breasts who may be at increased risk of side effects. [ABSTRACT FROM AUTHOR]

Purpose: Our institution was an early adopter of 5-fraction accelerated partial breast irradiation (ABPI) to treat women with early-stage breast cancer. This study reports long-term oncologic and cosmetic outcomes. Methods: We included patients receiving APBI 600 cGy × 5 fx delivered every other day or every day between 2010 and 2022. Logistic regression models were used to identify factors associated with development of late toxicities, clinician, and patient-rated cosmesis. Kaplan–Meier methodology was used to calculate overall survival (OS), disease-free survival (DFS), and locoregional recurrence-free survival (LR-RFS). Results: 442 patients received APBI either daily (56%) or every other day (44%) in the prone position (92%). At a median follow-up of 48 months (range: 5.96–155 months), 12 (2.7%) patients developed a local recurrence (LR). Out of 258 patients with > 3-month toxicity data available, the most common late grade ≥ 2 adverse event was breast fibrosis (6.2%). On multivariate analysis, daily APBI treatment (vs every other day) did not correlate with an increased risk of any late grade ≥ 2 toxicity though it did correlate with a lower risk of any late grade ≥ 2 fibrosis. Overall, at a median follow-up of 80 months, the rates of good–excellent physician and patient-rated cosmesis were 95% and 85%, respectively, with no difference between patients treated on consecutive vs. every other day. On multivariate analysis, patients who did not receive any adjuvant therapy were at increased risk of developing a LR. Five-year OS, LRFS, and DFS were 97.2%, 97.7%, and 89.5%, respectively. Conclusions: Five-fraction APBI delivered primarily in the prone position either daily or every other day was effective with low rates of local recurrence, minimal toxicity, and excellent cosmesis at long-term follow-up. [ABSTRACT FROM AUTHOR]

Purpose We investigated the proportions of patients eligible for accelerated partial breast irradiation (APBI) among those with pT1- 2N0 breast cancer, based on the criteria set by the American Society for Radiation Oncology (ASTRO), the Groupe Européen de Curiethérapie and the European Society for Radiotherapy and Oncology (GEC-ESTRO), the American Brachytherapy Society (ABS), and the American Society of Breast Surgeons (ASBS). Additionally, we analyzed the rate of APBI utilization among eligible patients. Materials and Methods Patients diagnosed with pT1-2N0 breast cancer in 2019 were accrued in four tertiary medical centers in Korea. All patients had undergone breast conserving surgery followed by radiotherapy, either whole breast irradiation or APBI. To determine which guideline best predicts the use of APBI in Korea, the F1 score and Matthews correlation coefficient (MCC) were determined for each guideline. Results A total of 1,251 patients were analyzed, of whom 196 (15.7%) underwent APBI. The percentages of eligible patients identified by the ASTRO, GEC-ESTRO, ABS, and ASBS criteria were 13.7%, 21.0%, 50.5%, and 63.5%, respectively. APBI was used to treat 54.4%, 37.2%, 27.1%, and 23.7% of patients eligible by the ASTRO, GEC-ESTRO, ABS, and ASBS criteria, respectively. The ASTRO guideline exhibited the highest F1 score (0.76) and MCC (0.67), thus showing the best prediction of APBI utilization in Korea. Conclusion The proportion of Korean breast cancer patients who are candidates for APBI is substantial. The actual rate of APBI utilization among eligible patients may suggest there is a room for risk-stratified optimization in offering radiation therapy. [ABSTRACT FROM AUTHOR]

This study investigated the cosmetic degradation and toxicity for an accelerated partial breast irradiation (APBI) prescription delivered in 5 fractions over 1 week and compared the outcomes with those of whole breast irradiation (WBI). The trial was a multicenter, single-arm, phase 2 prospective cohort study. Eligible women 50 years of age or older with estrogen receptor–positive and human epidermal growth factor receptor 2–negative invasive ductal carcinoma or ductal carcinoma in situ after breast-conserving surgery received 27 Gy in 5 daily fractions of APBI. The primary endpoint was noninferiority of 2-year cosmesis using the RAPID trial's WBI arm as the control arm. A global consensus cosmetic score using a European Organisation for Research and Treatment of Cancer rating scale score of excellent, good, fair, or poor for each patient at baseline and 2 years was generated by a panel of 5 radiation oncologists using photographs of treated and untreated breasts. From 2016 to 2019, 298 eligible women were enrolled. By the 2-year follow-up, 76 patients had been lost or withdrawn and 3 had died, resulting in 219 patients available for complete, 2-year photographic cosmetic evaluation. The median follow-up for all participants was 4.7 years (IQR, 3.8-5.5 years). No patient had a fair or poor cosmetic score at the 2-year evaluation. Cosmesis was better or unchanged for 97% of patients and worse for 3% (excellent to good), and no cosmetic failures occurred. The confidence intervals were 0.88 (0.86-0.90) and 1.00 (0.99-1.00) for the RAPID and ACCEL trials, respectively. Cosmetic degradation with 5 daily treatments of the ACCEL trial's APBI intervention is noninferior to the WBI arm of the RAPID trial. [ABSTRACT FROM AUTHOR]

Consistency of nomenclature within radiation oncology is increasingly important as big data efforts and data sharing become more feasible. Automation of radiation oncology workflows depends on standardized contour nomenclature that enables toxicity and outcomes research, while also reducing medical errors and facilitating quality improvement activities. Recommendations for standardized nomenclature have been published in the American Association of Physicists in Medicine (AAPM) report from Task Group 263 (TG-263). Transitioning to TG-263 requires creation and management of structure template libraries and retraining of staff, which can be a considerable burden on clinical resources. Our aim is to develop a program that allows users to create TG-263–compliant structure templates in English, Spanish, or French to facilitate data sharing. Fifty-three premade structure templates were arranged by treated organ based on an American Society for Radiation Oncology (ASTRO) consensus paper. Templates were further customized with common target structures, relevant organs at risk (OARs) (eg, spleen for anatomically relevant sites such as the gastroesophageal junction or stomach), subsite- specific templates (eg, partial breast, whole breast, intact prostate, postoperative prostate, etc) and brachytherapy templates. An informal consensus on OAR and target coloration was also achieved, although color selections are fully customizable within the program. The resulting program is usable on any Windows system and generates template files in practice-specific Digital Imaging and Communications In Medicine (DICOM) or XML formats, extracting standardized structure nomenclature from an online database maintained by members of the TG-263U1, which ensures continuous access to up-to-date templates. We have developed a tool to easily create and name DICOM radiation therapy (DICOM-RT) structures sets that are TG-263–compliant for all planning systems using the DICOM standard. The program and source code are publicly available via GitHub to encourage feedback from community users for improvement and guide further development. [ABSTRACT FROM AUTHOR]

The multiple domains of development covered by the Sustainable Development Goals (SDGs) present a practical challenge for governments. This is particularly acute in highly resource-constrained settings which use a sector-by-sector approach to structure financing and prioritization. One potentially under-prioritized solution is to implement interventions with the potential to simultaneously improve multiple outcomes across sectors, what United Nations Development Programme refer to as development 'accelerators'. An increasing number of accelerators are being identified in the literature. There are, however, challenges associated with the evaluation and implementation of accelerators. First, as accelerators have multiple benefits, possibly in different sectors, they will be undervalued if the priority setting is conducted sector-by-sector. Second, even if their value is recognized, accelerators may not be adopted if doing so clashes with any of the multiple competing interests policymakers consider, of which efficiency/social desirability is but one. To illustrate the first challenge, and outline a possible solution, we conduct a cost-effectiveness analysis comparing the implementation of three sector-specific interventions to an accelerator, first using a sector-by-sector planning perspective, then a whole of government approach. The case study demonstrates how evaluating the cost-effectiveness of interventions sector-by-sector can lead to suboptimal efficiency rankings and overlook interventions that are efficient from a whole of government perspective. We then examine why recommendations based on a whole of government approach to evaluation are unlikely to be heeded. To overcome this second challenge, we outline a menu of existing and novel financing mechanisms that aim to address the mismatch between political incentives and logistical constraints in the priority setting and the economic evaluation evidence for cost-effective accelerators. These approaches to financing accelerators have the potential to improve efficiency, and in doing so, progress towards the SDGs, by aligning political incentives more closely with recommendations based on efficiency rankings. [ABSTRACT FROM AUTHOR]

Background: Accelerated partial breast irradiation (APBI) is an alternative breast-conserving therapy approach where radiation is delivered in less time compared to whole breast irradiation (WBI), resulting in improved patient convenience, less toxicity, and cost savings. This prospective randomized study compares the external beam APBI with commonly used moderate hypofractionated WBI in terms of feasibility, safety, tolerance, and cosmetic effects. Methods: Early breast cancer patients after partial mastectomy were equally randomized into two arms– external APBI and moderate hypofractionated WBI. External beam technique using available technical innovations commonly used in targeted hypofractionated radiotherapy to minimize irradiated volumes was used (cone beam computed tomography navigation to clips in the tumor bed, deep inspiration breath hold technique, volumetric modulated arc therapy dose application, using flattening filter free beams and the six degrees of freedom robotic treatment couch). Cosmetics results and toxicity were evaluated using questionnaires, CTCAE criteria, and photo documentation. Results: The analysis of 84 patients with a median age of 64 years showed significantly fewer acute adverse events in the APBI arm regarding skin reactions, local and general symptoms during a median follow-up of 37 months (range 21–45 months). A significant difference in favor of the APBI arm in grade ≥ 2 late skin toxicity was observed (p = 0.026). Late toxicity in the breast area (deformation, edema, fibrosis, and pain), affecting the quality of life and cosmetic effect, occurred in 61% and 17% of patients in WBI and APBI arms, respectively. The cosmetic effect was more favorable in the APBI arm, especially 6 to 12 months after the radiotherapy. Conclusion: External APBI demonstrated better feasibility and less toxicity than the standard regimen in the adjuvant setting for treating early breast cancer patients. The presented study confirmed the level of evidence for establishing the external APBI in daily clinical practice. Trial registration: NCT06007118. [ABSTRACT FROM AUTHOR]

HER2-positive (HER2+) breast cancer historically exhibited the most adverse local outcomes and, consequently, has had limited representation among trials of partial breast irradiation (PBI). We hypothesized that with contemporary HER2-targeted agents, patients may now exhibit excellent disease control outcomes after adjuvant PBI. Using a prospectively maintained institutional database, we identified patients with HER2+ breast cancer treated with breast conserving surgery (BCS) and PBI from 2000 to 2022. Salient clinicopathologic and treatment parameters were collected. All patients received external beam PBI to 40 Gy in 10 daily fractions. Cumulative incidence functions were calculated to estimate the incidence of local recurrence (LR) with the competing risk of death. We identified 1248 patients who underwent PBI at our institution, of whom the study cohort comprised 52 (4%) with HER2+ breast cancer (median age, 64 years; range, 44-87). Nearly all had T1 tumors (98%; median size, 12 mm [range, 1-21 mm]). Most had estrogen receptor positive disease (88%), and all patients had negative surgical margins. Nearly all underwent sentinel node biopsy (94%), with the remainder undergoing no surgical axillary evaluation. Forty-two (81%) received chemotherapy; 40 (77%), hormone therapy; and 42 (81%), HER2-directed therapy, most commonly trastuzumab. At 143.8 person-years of follow-up (range, 7-226 months for each patient), we observed 2 LR events at 14 and 26 months, respectively, yielding a 2-year LR rate of 3.8%. No regional or distant recurrences were observed, nor were any breast-specific mortality events. Two deaths were observed, both without evidence of disease. Among a cohort of patients with HER2+ early-stage breast cancer managed with BCS and PBI, we observed a 2-year LR rate of 3.8%, with no regional or distant recurrences and excellent overall survival. These findings require confirmation with longer follow-up among larger cohorts but appear consistent with the excellent results of contemporary randomized trials of PBI unselected for HER2 status. [ABSTRACT FROM AUTHOR]

Whole breast irradiation after breast‐conserving surgery for early breast cancer has become one of the standard treatment modes for breast cancer and yields the same effect as radical surgery. Accelerated partial breast irradiation (APBI) as a substitute for whole breast irradiation for patients with early breast cancer is a hot spot in clinical research. APBI is characterised by simple high‐dose local irradiation of the tumour bed in a short time, thus improving convenience for patients and saving costs. The implementation methods of APBI mainly include brachytherapy, external beam radiation therapy, and intraoperative radiotherapy. This review provides an overview of the clinical effects and adverse reactions of the main technologies of APBI and discusses the prospects for the future development of APBI. [ABSTRACT FROM AUTHOR]

Background Literature addressing the risks associated with increasing body mass index (BMI) for patients undergoing free flap breast reconstruction is limited. Often, an arbitrary BMI cutoff (i.e., BMI of 30 kg/m 2) is used to determine candidacy for a free flap without substantial backing evidence. This study utilized a national multi-institutional database to analyze outcomes of free flap breast reconstruction and stratified complications by BMI class. Methods Using the 2010 to 2020 National Surgical Quality Improvement Program database, patients who underwent free flap breast reconstruction were identified. Patients were divided into six cohorts based on the World Health Organization BMI classes. Cohorts were compared by basic demographics and complications. A multivariate regression model was created to control for age, diabetes, bilateral reconstruction, American Society of Anesthesiologists class, and operative time. Results Surgical complications increased with each BMI class, with the highest rates occurring in class I, II, and III obesity, respectively. In a multivariable regression model, the risk for any complication was significant for class II and III obesity (odds ratio [OR]: 1.23, p < 0.004; OR: 1.45, p < 0.001, respectively). Diabetes, bilateral reconstruction, and operative time were independently associated with an increased risk of any complication (OR: 1.44, 1.14, 1.14, respectively, p < 0.001). Conclusion This study suggests that the risks of postoperative complications following free flap breast reconstruction are highest for patients with a BMI greater than or equal to 35 kg/m 2 , having nearly 1.5 times higher likelihood of postoperative complications. Stratifying these risks by weight class can help guide preoperative counseling with patients and help physicians determine candidacy for free flap breast reconstruction. [ABSTRACT FROM AUTHOR]

Background: This study investigated the differences in target volumes between preoperative magnetic resonance imaging (MRIpre) and postoperative MRI (MRIpost) for breast radiotherapy after breast‐conserving surgery (BCS) using deformable image registration (DIR). Methods and Materials: Seventeen eligible patients who underwent whole‐breast irradiation in the prone position after BCS were enrolled. On MRIpre, the gross tumor volume (GTV) was delineated as GTVpre, which was then expanded by 10 mm to represent the preoperative lumpectomy cavity (LC), denoted as LCpre. The LC was expanded to the clinical target volume (CTV) and planning target volume (PTV) on the MRIpre and MRIpost, denoted as CTVpre, CTVpost, PTVpre, and PTVpost, respectively. The MIM software system was used to register the MRIpre and MRIpost using DIR. Differences were evaluated regarding target volume, distance between the centers of mass (dCOM), conformity index (CI), and degree of inclusion (DI). The relationship between CILC/CIPTV and the clinical factors was also assessed. Results: Significant differences were observed in LC and PTV volumes between MRIpre and MRIpost (p < 0.0001). LCpre was 0.85 cm3 larger than LCpost, while PTVpre was 29.38 cm3 smaller than PTVpost. The dCOM between LCpre and LCpost was 1.371 cm, while that between PTVpre and PTVpost reduced to 1.348 cm. There were statistically significant increases in CI and DI for LCpost–LCpre and PTVpost–PTVpre (CI = 0.221, 0.470; DI = 0.472, 0.635). No obvious linear correlations (p > 0.05) were found between CI and GTV, primary tumor volume‐to‐breast volume ratio, distance from the primary tumor to the nipple and chest wall, and body mass index. Conclusions: Despite using DIR technology, the spatial correspondence of target volumes between MRIpre and MRIpost was suboptimal. Therefore, relying solely on preoperative diagnostic MRI with DIR for postoperative LC delineation is not recommended. [ABSTRACT FROM AUTHOR]

To determine cardiac dose received by patients treated with high dose rate interstitial brachytherapy. Patients with early-stage, node negative breast cancer can be treated using multi-catheter interstitial brachytherapy accelerated partial breast irradiation (MIB-APBI), with the benefit of reduced treatment volumes and favorable toxicity. We conducted a retrospective review of left-sided breast cancer patients treated using MIB-APBI at our institution since 2014. The mean heart dose (MHD) was calculated using the Oncentra 3.2 planning system. The minimum distance between the planning target volume (PTVeval) and heart contour was measured manually. 81 patients were included. The upper outer quadrant was the most common site. The MHD was 97.8 cGy (EQD2a/b=2) (range 22–229 cGy). MHD significantly correlated with the closest distance between PTVeval and heart contour (correlation coefficient -0.823, p <0.001); size of PTVeval (cc) and quadrant location did not. Appropriately selected women with early-stage, low-risk, left-sided breast cancer who received MIB-APBI had acceptable MHD. There was a strong correlation between the distance of PTVeval and MHD. Quadrant breast tumor is in cannot be used as a surrogate for MHD in brachytherapy. Our findings contribute to the growing evidence of the utility and safety of MIB-APBI. [ABSTRACT FROM AUTHOR]

Assess the local recurrence rate and global survival rate among women diagnosed with breast cancer who underwent intraoperative electron radiotherapy (IOERT) between 2007 and 2017, in a single private healthcare setting in Belo Horizonte, Brazil. This is a retrospective study based on medical records about the outcomes of patients submitted to breast-conserving surgery followed by IOERT. The collected variables included the patient's profile and tumor features, IOERT isodose, and outcomes. The quantitative data were presented in tables of frequency. The survival curves were created with the Kaplan-Meier method. In all tests, the adopted relevance level was 5%. The analyses were carried out with SPSS version 25.0. The samples consisted of 78 patients, among which a total of 14 (17.9%) recurrences were observed. The median time of recurrence was 49 months after the IOERT was performed. Of the 78 patients analyzed, 13 (16.7%) died, 5 (6.4%) of which were due to breast cancer. The global survival rate in 5 years was 94.9% and 90.4% in 10 years. The local recurrence rate in 5 years was 89.7% and 86.4% in 10 years. Our findings revealed a higher local recurrence rate than the literature data. However, our results also showed that patients classified as low-risk had an overall survival of 5 and 10 years similar to other studies in the literature, reaffirming that low-risk women can benefit from IOERT. Given this finding, it is reaffirmed that rigorous eligibility criteria for IOERT are critical to reducing local recurrence. [ABSTRACT FROM AUTHOR]

Purpose: Breast brachytherapy (BB) represents an important radiation therapy modality in modern breast cancer treatments. Currently, BB is mainly used for accelerated partial breast irradiation (APBI), local boost after whole breast radiation therapy (WBRT), and as salvage re-irradiation after second lumpectomy (APBrl). Two multi-catheter interstitial brachytherapy (MIB) techniques can be offered: intra-operative (IOB) and post-operative (POB) brachytherapy. The aim of this article was to summarize current available data on these two different brachytherapy approaches for breast cancer. Material and methods: A literature search was performed, and different experiences published by BB expert teams were analyzed and compared. These two different brachytherapy approaches for breast cancer have also been presented and discussed during meetings of the GEC-ESTRO BCWG. In addition, expert recommendations were defined. Results: A comprehensive description and practical comparison of both the techniques, i.e., IOB and POB, considering the latest available published data were presented. Different technical, logistic, and clinical aspects of both the methods were thoroughly examined and analyzed. This detailed comparison of the two breast brachytherapy techniques was supported by scientific data from extensive experience of experts, facilitating an objective analysis that, to our knowledge, has not been previously published. Conclusions: Based on the comprehensive analysis of both the brachytherapy techniques available, this article serves as a valuable resource to guide breast teams in selecting the optimal BB technique (POB or IOB), considering hospital environment, multi-disciplinary collaboration, and patient logistics. [ABSTRACT FROM AUTHOR]

Background: A Japanese multi-institutional prospective study was initiated to investigate the effectiveness and safety of accelerated partial breast irradiation (APBI) using strut-adjusted volume implant (SAVI) brachytherapy, with subjects registered between 2016 and 2021. Herein, we report the preliminary results on the feasibility of this treatment modality in Japan, focusing on the registration process, dosimetry, and acute toxicities. Patients and methods: Primary registration was conducted before breast-conserving surgery (BCS) and the eligibility criteria included the following: age ≥ 40 years, tumor unifocal and unicentric, ≤ 3 cm in diameter, cN0M0, proven ductal, mucinous, tubular, medullary, or lobular carcinoma by needle biopsy. Secondary registration was conducted after BCS had been performed leaving a cavity for device implantation and pathological evaluations, and the eligibility criteria were as follows: negative surgical margin, tumor ≤ 3 cm in diameter on gross pathological examination, histologically confirmed ductal, mucinous, tubular medullary, colloid, or lobular carcinoma, pN0, L0V0, no extensive ductal component, no initiation of chemotherapy within 2 weeks of the brachytherapy APBI planning with SAVI was performed for the patients successfully entered in the study by the secondary registration process, and the treatment was administered at the dose of 34 Gy in 10 fractions administered twice daily. Results: Between 2016 and 2021, 64 women were enrolled in the study through primary registration, of which 19 were excluded from the secondary registration process, and in one, it was deemed impossible to comply with the dose constraints established during treatment planning. After the exclusion of these latter 20 patients, we treated the remaining 44 patients by APBI with SAVI. The dose constraints could be adhered to in all the patients, but re-planning was necessitated in 3 patients because of applicator movement during the treatment period. Grade 2 acute toxicities were observed in 18% of all patients, but more severe acute toxicities than Grade 2 were not observed in any of the patients. Conclusion: APBI with SAVI brachytherapy is feasible in Japan from the aspects of compliance with dose constraints and frequency of acute toxicities. [ABSTRACT FROM AUTHOR]

For second ipsilateral breast tumor event (2nd IBTE), second conservative treatment (2nd CT) combining lumpectomy plus accelerated partial breast reirradiation (APBrI) represents a curative option. The aim of this study was to analyze oncological prognostic factors for patients with a 2nd IBTE treated with 2nd CT. An analysis of clinical practices was conducted across 7 academic hospitals/cancer centers in 6 European countries based on the GEC-ESTRO database. Patients presenting a 2nd IBTE occurring after conservative surgery (lumpectomy + axillary evaluation) and irradiation performed for the primary tumor underwent a 2nd CT with brachytherapy-based APBrI. The main outcome was 5-year cumulative incidence (CI) rate of second local relapse. All analyzed patients were classified according to risk groups for Groupe Européen de Curiethérapie–European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) accelerated partial breast irradiation (APBI) and molecular classification and time interval between first and second breast surgery (TI S1S2). Finally, we combined GEC-ESTRO APBI, molecular, and TI S1S2 risk groups, leading to the definition of a new score (named TAM: score based on the combination of time interval [T] between first and second surgery and APBI [A] and molecular [M] classifications) specifically designed for 2nd IBTE oncological outcome analysis. From July 1994 to January 2021, a total of 508 patients received a 2nd CT. At the time of 2nd IBTE, median age was 64.6 years (range, 56.2-72.6). With a median follow-up of 60.9 months (56.2-72.6), the 5-year second local relapse CI rate was 4% (95% confidence interval [95% CI], 2%-6%). The 5-year distant metastasis disease CI rate was 7% (95% CI, 4%-10%). Five-year disease-free and overall survival rates were 89% (95% CI, 86%-93%) and 91% (95% CI, 88%-94%), respectively. In multivariate analysis, TAM score was an independent prognostic factor for all the oncological items (P <.001) except disease-specific survival (P =.07) and overall survival (P =.09). The grade ≥3 late toxicity rate was 12.1%. This analysis of 2nd CT combining lumpectomy with APBrI for 2nd IBTE confirmed the excellent oncological results obtained after 2nd CT. Furthermore, the GEC-ESTRO TAM score appears to be an important prognostic factor, assisting patients and physicians in the decision-making process. [ABSTRACT FROM AUTHOR]

Purpose: We evaluate various approaches to target volume definition and boost delivery in patients with complete response to neoadjuvant systemic therapy (NST) who were treated by radiotherapy without a surgery. Materials and Methods: A pathological complete response (pCR) was diagnosed in 21 of 27 patients included in "surgery de-escalation" prospective observation study. Clips were placed in the primary tumor volume (PrTV) before NST and during the vacuum aspiration biopsy. Twenty patients with pCR underwent the whole breast irradiation and a boost to the PrTV. High-dose rate brachytherapy (HDRB) was the basic technique for boost delivery. Finally, we identified the value of fused images (computed tomography [CT] before NST with simulation CT), clips and their combination for an accurate boost delivery. Results: A complete overlap between PrTV on pre-treatment CT with the localization of the clips on simulation CT was mentioned in 10, partial mismatch in three patients. In 12 of these 13 women, HDRB was successfully used for the boost delivery. In five cases we mentioned a marked discrepancy between the PrTV on fused images and the topography of the clips. In other two women we did not find clips on simulation CT. The fused images in five of these seven patients showed anatomical landmarks (scar, fibrosis) used for identification of the gross tumor volume. In all 20 women with pCR (average follow-up of 16.6 months), there were no locoregional recurrences. Conclusion: Combination of the clips with fusion of pre-NST and simulation CTs is important for an accurate boost delivery. [ABSTRACT FROM AUTHOR]

Different sterilization doses of the electron beam (E‐beam) will change the properties of biomaterials and affect their clinical application. Acellular porcine cornea (APC) is a promising corneal substitute to alleviate the shortage of corneal resources. The residual DNA was significantly reduced to 18.50 ± 3.19 ng/mg, and the clearance rate of α‐Gal was close to 100% after the treatment with freezing–thawing combined enzyme, indicating that the decellularization was effective. The effects of different E‐beam doses at 0, 2, 8, 15, and 25 kGy on the APC were studied. With the increase in irradiation dose, the transmittance, tensile strength, and swelling ratio of APC gradually decreased, but the resistance to enzymatic degradation was stronger than that of non‐irradiated APC, especially at 8 kGy. The structure of APC was denser after irradiation, but the dose of 25 kGy could cause partial collagen fiber fracture and increase the pore size. The cell viability of the APC irradiated by 15 and 25 kGy were greater than 80%. After the implantation in rabbit corneas, there was no obvious neovascularization and inflammation, but the dose of 25 kGy had a more destructive effect on the chemical bonds of collagen, which made the APC easier to be degraded. The thickness of APC in the 25 kGy group was thinner than that in the 15 kGy group 1 year after surgery, and the epithelium grew more slowly, so the E‐beam dose of 15 kGy might be more suitable for the sterilization of APC. [ABSTRACT FROM AUTHOR]

The light emitting diodes (LEDs) used in surgical fluorescence microscopes have weak power, to induce fluorescence emission. The LED induces fluorescence emission throughout a lesion due to its large beam width; however, the beam irradiation intensity is not uniform within the beam width, resulting in a fluorescence emission induction difference. To overcome this problem, this study proposes an asymmetric irradiation array for supplying power uniformly throughout the beam width of the LED and increasing the intensity of the LED. To increase the irradiation power of the LEDs, a multi-asymmetric irradiation method with a ring-type array structure was used. The LED consisted of eight rings, and the space between the LEDs, the placement position, and the placement angle were analyzed to devise an experimental method using 3D printing technology. To test the irradiation power of the LED, the working distance (WD) between the LED and target was 30 cm. The bias voltage of the LED for irradiating the light source was 5.0 V and the measured power was 4.63 mW. The brightness (lux) was 1153 lx. Consequently, the LED satisfied the fluorescence emission induction conditions. The diameter of the LED-irradiated area was 9.5 cm. Therefore, this LED could be used to observe fluorescent emission-guided lesions. This study maximized the advantages of LEDs with optimal conditions for fluorescence emission by increasing the beam width, irradiation area, and energy efficiency, using a small number of LEDs at the maximum WD. The proposed method, optimized for fluorescence expression-induced surgery, can be made available at clinical sites by mass producing them through semiconductor processes. [ABSTRACT FROM AUTHOR]

Skin reaction is a common toxicity during oncology management, especially followed during the radiotherapy. Its assessment and understanding of the factors influencing its occurrence, is a major issue in the management of patients treated for an early breast cancer (BC). We evaluated 8561 patients during their overall management for a BC. We focus on specific skin toxicities: erythema, fibrosis, telangiectasia and changes of skin colour. These toxicities were assessed at the baseline defined as 0‐3‐6 (M0), 12 (M12), 36 (M36) and 60 (M60) months. The prevalence of toxicities of interest varied over time, so at M0, 30.4% of patients had erythema while 17.7% of patients had fibrosis. At M60, the prevalence of erythema was 2%, while fibrosis remained stable at about 19%. After adjustments, at M0, there was a significant association between the onset of cutaneous erythema and obesity, the presence of axillary dissection, the type of surgery and the tumour phenotype RH+/HER2+. Concerning fibrosis, a significant association was found, at M12, with the age of the patient, obesity, Charlson score and type of surgery. Concerning the modification of skin colour at M12, we find a link between the age of the patient, obesity, tobacco consumption and alcohol consumption. The prevention of this toxicity is a major issue for the quality of life. Our results allow us to understand the risk of developing skin toxicity in a patient, depending on her intrinsic, tumour or therapeutic characteristics and to implement adapted means of prevention and monitoring. [ABSTRACT FROM AUTHOR]

Background: Radiation pneumonitis (RP) is one of the common side effects after adjuvant radiotherapy in breast cancer. Irradiation dose to normal lung was related to RP. We aimed to propose an organ features based on deep learning (DL) model and to evaluate the correlation between normal lung dose and organ features. Methods: Patients with pathology-confirmed invasive breast cancer treated with adjuvant radiotherapy following breast-conserving surgery in four centers were included. From 2019 to 2020, a total of 230 patients from four nationwide centers in China were screened, of whom 208 were enrolled for DL modeling, and 22 patients from another three centers formed the external testing cohort. The subset of the internal testing cohort (n = 42) formed the internal correlation testing cohort for correlation analysis. The outline of the ipsilateral breast was marked with a lead wire before the scanning. Then, a DL model based on the High-Resolution Net was developed to detect the lead wire marker in each slice of the CT images automatically, and an in-house model was applied to segment the ipsilateral lung region. The mean and standard deviation of the distance error, the average precision, and average recall were used to measure the performance of the lead wire marker detection model. Based on these DL model results, we proposed an organ feature, and the Pearson correlation coefficient was calculated between the proposed organ feature and ipsilateral lung volume receiving 20 Gray (Gy) or more (V20). Results: For the lead wire marker detection model, the mean and standard deviation of the distance error, AP (5 mm) and AR (5 mm) reached 3.415 ± 4.529, 0.860, 0.883, and 4.189 ± 8.390, 0.848, 0.830 in the internal testing cohort and external testing cohort, respectively. The proposed organ feature calculated from the detected marker correlated with ipsilateral lung V20 (Pearson correlation coefficient, 0.542 with p < 0.001 in the internal correlation testing cohort and 0.554 with p = 0.008 in the external testing cohort). Conclusions: The proposed artificial Intelligence-based CT organ feature was correlated with normal lung dose in adjuvant radiotherapy following breast-conserving surgery in patients with invasive breast cancer. Trial registration: NCT05609058 (08/11/2022). [ABSTRACT FROM AUTHOR]

Purpose/objective: Adjuvant whole breast radiotherapy and systemic therapy are part of the current evidence-based treatment protocols for early breast cancer, after breast-conserving surgery. Numerous randomized trials have investigated the therapeutic effects of partial breast irradiation (PBI) compared to whole breast irradiation (WBI), limiting the treated breast tissue. These trials were designed to achieve equal control of the disease with possible reduction in adverse events, improvements in cosmesis and quality of life (QoL). In this meta-analysis, we aimed to investigate the differences between PBI and WBI in side effects and QoL. Material/methods: We performed a systematic literature review searching for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was performed using the published event rates and the effect-sizes for available acute and late adverse events. Additionally, we evaluated cosmetic outcomes as well as general and breast-specific QoL using the EORTC QLQ-C30 and QLQ-BR23 questionnaires. Results: Sixteen studies were identified (n = 19,085 patients). PBI was associated with a lower prevalence in any grade 1 + acute toxicity and grade 2 + skin toxicity (OR = 0.12; 95% CI 0.09–0.18; p < 0.001); (OR = 0.16; 95% CI 0.07–0.41; p < 0.001). There was neither a significant difference in late adverse events between the two treatments, nor in any unfavorable cosmetic outcomes, rated by either medical professionals or patients. PBI-technique using EBRT with twice-daily fractionation schedules resulted in worse cosmesis rated by patients (n = 3215; OR = 2.08; 95% CI 1.22–3.54; p = 0.007) compared to WBI. Maximum once-daily EBRT schedules (n = 2071; OR = 0.60; 95% CI 0.45–0.79; p < 0.001) and IORT (p = 0.042) resulted in better cosmetic results grade by medical professionals. Functional- and symptom-based QoL in the C30-scale was not different between PBI and WBI. Breast-specific QoL was superior after PBI in the subdomains of "systemic therapy side effects" as well as "breast-" and "arm symptoms". Conclusion: The analysis of multiple randomized trials demonstrate a superiority of PBI in acute toxicity as well breast-specific quality of life, when compared with WBI. Overall, late toxicities and cosmetic results were similar. PBI-technique with a fractionation of twice-daily schedules resulted in worse cosmesis rated by patients. [ABSTRACT FROM AUTHOR]

The aim of this work was to prospectively evaluate the toxicity and cosmetic outcomes of 5-fraction, stereotactic, accelerated partial breast irradiation (APBI). This prospective observational cohort study enrolled women who underwent APBI for invasive carcinoma or carcinoma in situ of the breast. APBI was delivered using a CyberKnife M6 robotic radiosurgery system at 30 Gy in 5 nonconsecutive, once-daily fractions. Women undergoing whole breast irradiation (WBI) were also enrolled for comparison. Patient-reported and physician-assessed adverse events were recorded. Breast fibrosis was measured using a tissue compliance meter, and breast cosmesis was assessed using BCCT.core (an automatic, computer-based software). Outcomes were collected until 24 months posttreatment according to the study protocol. In total, 204 patients (APBI, n = 103; WBI, n = 101) were enrolled. Regarding patient-reported outcomes, the APBI group reported significantly less skin dryness (6.9% vs 18.3%; P =.015), radiation skin reaction (9.9% vs 23.5%; P =.010), and breast hardness (8.0% vs 20.4%; P =.011) at 6 months than the WBI group. On physician assessment, the APBI group had significantly less dermatitis at 12 months (1.0% vs 7.2%; P =.027) than the WBI group. Any severe toxicities after APBI were rare in patient-reported outcomes (score ≥3, 3.0%) and physician assessments (grade ≥3, 2.0%). In the uninvolved quadrants, measured fibrosis in the APBI group was significantly lower than that in the WBI group at 6 (P =.001) and 12 (P =.029) months but not at 24 months. In the involved quadrant, measured fibrosis in the APBI group was not significantly different from that in the WBI group at any time. Cosmetic outcomes in the APBI group were mostly excellent or good (77.6%) at 24 months, and there was no significant cosmetic detriment from the baseline. Stereotactic APBI was associated with less fibrosis in the uninvolved breast quadrants than WBI. Patients showed minimal toxicity and no detrimental effects on cosmesis after APBI. [ABSTRACT FROM AUTHOR]

Objective: The liver is a critical organ at risk during right breast radiotherapy (RT). Liver function tests (LFTs) such as alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transferase (GGT) serve as biochemical markers for hepatobiliary damage. In this multicenter cross-sectional study, the effects of liver dose–volume on changes in LFTs pre- and post-RT in patients treated for right breast cancer were evaluated. Materials and Methods: Between January 2019 and November 2022, data from 100 patients who underwent adjuvant right breast RT across three centers were retrospectively assessed. Target volumes and normal structures were contoured per the RTOG atlas. Patients were treated with a total dose of 50 Gy in 25 fractions to the CTV, followed by a boost to the tumor bed where indicated. The percentage change in LFT values in the first two weeks post-RT was calculated. Statistics were analyzed with SPSS version 22 software, with significance set at p < 0.05. Statistical correlation between liver doses (in cGy) and the volume receiving specific doses (Vx in cc) on the change in LFTs were analyzed using Kolmogorov–Smirnov, Mann–Whitney U test. Results: The median age among the 100 patients was 56 (range: 29–79). Breast-conserving surgery was performed on 75% of the patients. The most common T and N stages were T1 (53%) and N0 (53%), respectively. None of the patients had distant metastasis or simultaneous systemic treatment with RT. A total of 67% of the treatments utilized the IMRT technique and 33% VMAT. The median CTV volume was 802 cc (range: 214–2724 cc). A median boost dose of 10 Gy (range: 10–16 Gy) was applied to 28% of the patients with electrons and 51% with IMRT/VMAT. The median liver volume was 1423 cc (range: 825–2312 cc). Statistical analyses were conducted on a subset of 57 patients for whom all three LFT values were available both pre- and post-RT. In this group, the median values for AST, ALT, and GGT increased up to 15% post-RT compared to pre-RT, and a median liver Dmean below 208 cGy was found significant. While many factors can influence LFT values, during RT planning, attention to liver doses and subsequent regular LFT checks are crucial. Conclusion: Due to factors such as anatomical positioning, planning technique, and breast posture, the liver can receive varying doses during right breast irradiation. Protecting patients from liver toxicity secondary to RT is valuable, especially in breast cancer patients with a long-life expectancy. Our study found that, even in the absence of any systemic treatment or risk factors, there was an average increase of nearly 15% in enzymes, indicating acute liver damage post-RT compared with pre-RT. Attention to liver doses during RT planning and regular follow-up with LFTs is essential. [ABSTRACT FROM AUTHOR]

Acute radiation dermatitis (ARD) is common after radiation therapy for breast cancer, with data indicating that ARD may disproportionately affect Black or African American (AA) patients. We evaluated the effect of skin of color (SOC) on physician-reported ARD in patients treated with radiation therapy. We identified patients treated with whole breast or chest wall ± regional nodal irradiation or high tangents using 50 Gy in 25 fractions from 2015 to 2018. Baseline skin pigmentation was assessed using the Fitzpatrick scale (I = light/pale white to VI = black/very dark brown) with SOC defined as Fitzpatrick scale IV to VI. We evaluated associations among SOC, physician-reported ARD, late hyperpigmentation, and use of oral and topical treatments for RD using multivariable models. A total of 325 patients met eligibility, of which 40% had SOC (n = 129). On multivariable analysis, Black/AA race and chest wall irradiation had a lower odds of physician-reported grade 2 or 3 ARD (odds ratio [OR], 0.110; 95% confidence interval [CI], 0.030-0.397; P =.001; OR, 0.377; 95% CI, 0.161-0.883; P =.025), whereas skin bolus (OR, 8.029; 95% CI, 3.655-17.635; P = 0) and planning target volume D0.03cc (OR, 1.001; 95% CI, 1.000-1.001; P =.028) were associated with increased odds. On multivariable analysis, SOC (OR, 3.658; 95% CI, 1.236-10.830; P =.019) and skin bolus (OR, 26.786; 95% CI, 4.235-169.432; P = 0) were associated with increased odds of physician-reported late grade 2 or 3 hyperpigmentation. There was less frequent use of topical steroids to treat ARD and more frequent use of oral analgesics in SOC versus non-SOC patients (43% vs 63%, P <.001; 50% vs 38%, P =.05, respectively). Black/AA patients exhibited lower odds of physician-reported ARD. However, we found higher odds of late hyperpigmentation in SOC patients, independent of self-reported race. These findings suggest that ARD may be underdiagnosed in SOC when using the physician-rated scale despite this late evidence of radiation-induced skin toxicity. [ABSTRACT FROM AUTHOR]

It has been suspected that tumor resection surgery itself may accelerate breast cancer (BC) lung metastasis in some patients. Emodin, a natural anthraquinone found in the roots and rhizomes of various plants, exhibits anticancer activity. We examined the perioperative use of emodin in our established surgery wounding murine BC model. Emodin reduced primary BC tumor growth and metastasis in the lungs in both sham and surgical wounded mice, consistent with a reduction in proliferation and enhanced apoptosis (primary tumor and lungs). Further, emodin reduced systemic inflammation, most notably the number of monocytes in the peripheral blood and reduced pro‐tumoral M2 macrophages in the primary tumor and the lungs. Consistently, we show that emodin reduces gene expression of select macrophage markers and associated cytokines in the primary tumor and lungs of wounded mice. Overall, we demonstrate that emodin is beneficial in mitigating surgical wounding accelerated lung metastasis in a model of triple‐negative BC, which appears to be mediated, at least in part, by its actions on macrophages. These data support the development of emodin as a safe, low‐cost, and effective agent to be used perioperatively to alleviate the surgery triggered inflammatory response and consequential metastasis of BC to the lungs. [ABSTRACT FROM AUTHOR]

Partial breast reconstruction with a pedicled chest wall perforator flap (CWPF) enables breast conservation in a higher tumour: breast volume ratio scenario. Since there is limited evidence, this retrospective cohort study aimed to ascertain immediate (30-days) and medium-term (follow-up duration) surgical outcomes. STROBE-compliant protocol ascertained CWPF outcomes between March 2011–March 2021. UK centres known to perform CWPF were invited to participate if they performed at least 10 cases. Data were retrospectively collected, including patient demographics, tumour and treatment characteristics, and surgical and oncological outcomes. Statistical analysis (R™) included multivariable logistic regression and sensitivity analysis. Across 15 centres, 507 patients with median age (54 years, IQR; 48–62), body mass index (25.4 kg/m2, IQR; 22.5–29), tumour size (26 mm, IQR; 18–35), and specimen weight (62 g, IQR; 40–92) had following flap types: LiCAP (54.1%, n = 273), MiCAP/AiCAP (19.6%, n = 99), LiCAP + LTAP (19.8%, n = 100) and TDAP (2.2%, n = 11). 30-days complication rates were in 12%: haematoma (4.3%, n = 22), wound infection (4.3%, n = 22), delayed wound healing (2.8%, n = 14) and flap loss (0.6%, n = 3; 1 full) leading to readmissions (2.6%, n = 13) and re-operations (2.6%, n = 13). Positive margins (n = 88, 17.7%) led to 15.9% (n = 79) re-excisions, including 7.5% (n = 37) at the planned 2nd of 2-stage surgery and 1.8% (n = 9) mastectomy. At median 23 months (IQR; 11–39) follow-up, there were 1.2% (n = 6) symmetrisations; recurrences: local (1%), regional/nodal (0.6%) and distant (3.2%). This large multicentre cohort study demonstrates acceptable complication and margin re-excision rates. CWPF extends the range of breast conservation techniques. Further studies are required for long-term oncological outcomes. This is the analysis of the largest aggregated cohort of patients (n=507, 2011-2021, 15 UK centres) undergoing partial breast reconstruction with a pedicled chest wall perforator flap to avoid deformity following breast conservation. Data demonstrates its applicability in T1-T2 tumours (median size,26 mm, IQR;18-35) with re-excision rates of 15.9 (7.5% during the planned second stage) and 1.8% completion mastectomy. Postoperative complication rates were 4.3% haematoma, 4.3% wound infection, 2.8% delayed wound healing, and 0.2% total flap loss. This study demonstrates that CWPF is a valuable option for patients with a higher tumour-to-breast volume ratio who wish to pursue breast-conserving surgery. [Display omitted] • PartBreCon study : A retrospective cohort study of partial breast reconstruction. • 15 centres, n = 507; T2 (26 mm), Breast conservation in 73.4% A-C cups, BMI (25.4). • Chest Wall Perforator Flaps - LiCAP (54%), AiCAP (19%), LiCAP-LTAP (20%), TDAP (2%). • Shows acceptable complications (12%) - re-operations (2.6%), flap loss (0.6%). • Low Mastectomy (2%) & Low Symmetrisation (1%); FU (23 m), local recurrence (1%). [ABSTRACT FROM AUTHOR]

Aim: To investigate the impact of DIBH for heart sparing effect on left sided breast postoperative whole breast irradiation by comparing the dosimetric characteristics of 3D-CRT hybrid VMAT and pure VMAT treatment planning under DIBH condition.Materials and Methods: The primary CT data sets from previously treated left sided early breast cancer were used for pure volumetric arc therapy (VMAT) technique re-planning for the dosimetric characteristics comparison. A treatment plan of 3D-CRT hybrid VMAT technique was re-planned on the free breath (FB) condition for the investigation of the dosimetric characteristics comparison on DIBH condition. The prescribed dose for all the treatment plans was 42.5Gy in 16 fractions. All plans were optimized to cover 100% of the PTV by 95% of prescribed dose. The dosimetric differences among the 3 treatment plans for the 20 patients were analyzed using Wilcoxon signed-rank test, with p value< 0.05 considered statistically significant.Results: 3D-CRT hybrid VMAT using DIBH technique yielded the best results on the conformity index (CI) and homogeneity index (HI). By comparing this 3D-CRT hybrid VMAT technique using FB and DIBH technique, the mean heart dose (MHD) was reduced from 5.38Gy to 1.65Gy, respectively (p =0.001) and the left anterior descending coronary artery (LAD)0.03cc dose was reduced from 27.87Gy to 9.41Gy, respectively (p =0.001). 3D-CRT hybrid VMAT using DIBH technique significantly reduced the V5, V20 and D mean of the ipsilateral lung and D mean of the contralateral lung. The D5 of right breast was significantly reduced by 3D-CRT hybrid VMAT compared with VMAT using DIBH technique.Conclusion: The incorporation of DIBH into 3D-CRT hybrid VMAT technique provides the best benefits for the heart and the OAR with respect to the radiation dose-sparing effect without compromising the target conformity and homogeneity in the treatment planning. [ABSTRACT FROM AUTHOR]

Accelerated partial breast irradiation (APBI) with multicatheter technique is a standard treatment in patients with low-risk breast cancer. In our institution it has been performed perioperatively for the last 10 years. We report our experience and results with this technique, with the different treatment schemes used as a result of the evidence available at the time. Data from patients treated with APBI with perioperative HDR brachytherapy were evaluated. Inclusion criteria were: age ≥ 50 years, tumor size ≤3 cm, cN0, no evidence of distant metastases, hormone sensitive invasive tumors, her2 negative, ki67<25% and negative margins after lumpectomy. In situ tumors < 25 mm were eligible. Patients with tumors close to the skin (≤5mm), a known BRCA mutation, linfovascular invasion, extensive intraductal carcinoma, or multifocal disease were not included. All cases were presented to a multidisciplinary committee and evaluated by a radiation oncologist prior to surgery, and all patients had a pre-surgical functional imaging test (MRI or contrast enhaced spectral mammography). The tumor bed was marked with radiopaque markers. Catheters were implanted intraoperatively using a freehand technique after the pathologist ruled out axillary involvement and confirmed negative margins. Forty-eight hours after surgery, a CT scan and 3D planning were performed and a final pathology report was obtained. The fractionation used was either 34 Gy in 10 fractions, 30.1 Gy in 7 fractions, or 22.35 Gy in 3 fractions. Clinical and dosimetric data were collected (acute and late toxicity according to CTCAE, cosmetic assessment with De Wazer scale). Data were collected retrospectively in patients treated with 10 and 7 fractions and prospectively in patients treated with the ultra-accelerated technique. Between 2014 and 2024, 169 implants were evaluated in 166 patients. The median follow-up was 20 months. Patient, tumor and implant characteristics are shown in Table 1. Ipsilateral recurrence has been reported in one patient at 47 months post-treatment, and disease-free and cancer-specific survival rates were 99.4% and 100%, respectively. There were no acute or late grade 3 or greater toxicities. Acute and late grade 1-2 toxicities were observed in 9.6% and 10.8% of patients, respectively. Perioperative accelerated partial breast irradiation using the multicatheter technique is a safe and time-efficient treatment option for selected patients. Long-term tumor control results will be reported with further follow-up. Because toxicity data were collected retrospectively in some patients and prospectively in others, toxicity rates have not been compared; however, overall data are favorable with approximately 10% grade 1 and 2 toxicity rates. [ABSTRACT FROM AUTHOR]

To present dosimetric outcomes of Strut Adjusted Volumetric Implant (SAVI) brachytherapy treatment plans delivered over 4 years using Tri-fraction Radiation Therapy Used to Minimize Patient Hospital Trips (TRIUMPH-T) Trial at our institution; and investigation into a plan-coverage-complexity indicator. Retrospective analysis on dosimetric parameters derived from clinically delivered treatment plans using different size SAVI (Cianna Medicals, Aliso Viejo CA) applicators during 2019 and 2023 were performed. Treatment plans were prepared using Ir-192 source modeled in BrachyVision (Varian Medical Systems, Inc.) and Oncentra (Elekta Brachy, Veenendaal, The Netherlands) treatment planning systems. Triumph-T trial dose regimen (22.5 Gy in 3 fractions, Bi-daily, 6 hours apart) and dosimetric criterion were employed for APBI delivery. Target [PTV_Eval] and organs at risk (OAR) [chestwall and ribs] were delineated in accordance with NSABP-B39/RTOG-0413 and Triumph-T trials. A 3 mm skin rind was contoured, as institutional preference, for skin-sparing. V 90% ≥ 90% was desired for PTV_Eval with V 150% < 40cc and V 200% < 17 cc for high dose metrics and D 0.03cc < 100% and D 0.03cc < 110% for skin and chestwall/ribs, respectively. A PTV-ratio was defined in this study as the ratio of PTV_Eval to PTV 1cm (volume encompassing 1 cm expansion around lumpectomy cavity) and was analyzed for linear correlation with the PTV_Eval coverage (V 90%) metric to determine feasibility of serving as a plan-coverage-complexity indicator. Pearson correlation coefficient (with a two-tailed t-test of significance; p<0.05) was used. Our center treated 147 patients with median PTV_Eval volume of 67.1 cc [35.9 cc-116.1 cc] using SAVI brachytherapy, following the Triumph-T trial planning technique. Amongst these, twenty (n=20) cavities were treated with 6-1-mini SAVI, fifty-two (n=52) cavities with 6-1 SAVI, fifty (n=50) with 8-1 SAVI, and twenty-five (n=25) with 10-1 SAVI, and these cavity groups had a median volume of 9.7 cc [7.7 cc - 15.4 cc], 18.1 cc [14.9 cc - 22.8 cc], 33.3 cc [15.3 cc - 41.3 cc] and 53.1cc [21.9 cc - 65.4 cc], respectively. Excellent coverage was achieved for PTV_Eval with mean V 90% at 97.0% ± 2.3%. Mean V 150% and V 200% were at 28.2cc ± 3.5cc and 12.7cc ± 2.4cc, respectively. From 6-1-mini to 10-1 SAVI, V 150% and V 200% values increase from 20.4cc to 35.7cc and 10.8cc to 14.1cc, respectively. For OARs, the mean D 0.03cc to skin, chestwall, and ribs were 86.9% ± 15.5%, 88.7% ± 30.6% and 59.5% ± 23.4%, respectively, and were within tolerance. Average PTV-ratio values were 0.92 ± 0.08 for all plans evaluated. Starting from 6-1mini to the 10-1 SAVI, the Pearson correlation coefficients between PTV-ratio and V 90% were 0.86, 0.90, 0.77, and 0.72, (p<0.05) indicating a high correlation. Retrospective analysis from 147 patients treated at our institution show that SAVI- brachytherapy using a 3-fraction Triumph-T trial regimen is an efficient alternative for APBI. Treatment plans delivered met dosimetric constraints outlined in the trial with excellent target coverage, minimal hot-spots, and OAR sparing. A novel metric, PTV-ratio, serving as a plan-coverage-complexity indicator showed a positive correlation to V 90% for all SAVI applicators. [ABSTRACT FROM AUTHOR]

To evaluate efficacy results of the GEC-ESTRO phase 3 non-inferiority trial in subgroups of patients defined by the GEC-ESTRO and ASTRO patient selection criteria for APBI. Patients aged ≥ 40 years with low risk invasive breast cancer or ductal carcinoma in-situ after breast conserving surgery were randomized to receive either 50 Gy WBI with tumor bed boost of 10 Gy or APBI using multicatheter brachytherapy. 633/1184 patients were randomized to APBI using multicatheter brachytherapy. In the context of the current available complete results after 10 years follow-up, we report results of a supplementary sub-analysis of these latter 633 patients regarding 10-year local control rates, disease-free and overall survival results comparing subgroups categorized according to the GEC-ESTRO and ASTRO patient selection criteria for APBI. Of note, some of these criteria qualifying patients as more than low risk or as cautionary, respectively, did not occur in our patient cohort by design (c.f. in-/exclusion criteria). The trial is registered with ClinicalTrials.gov, NCT00402519. The 10-year local recurrence rate in the APBI arm was 3.5% (95% CI: 2.0-5.0%). Among 633 patients treated with multicatheter brachytherapy for APBI, according to ASTRO criteria altogether 423 patients (66.8%) were classified as "suitable", 195 (30.8%) as "cautionary" and 11 (1.7%) as "unsuitable"; in 4 cases no ASTRO categorization was possible. In the "suitable" and "cautionary" groups, the cumulative incidence (95% CI) of local recurrence at 10 years was 3.3% and 5.0% (p=0.61), respectively; difference 1.7% (95% CI: -2.0 to 5.5%). 10-year disease-free survival was 81.9% and 83.6% (p=0.63), respectively. According to GEC-ESTRO criteria, 430 patients (68%) were classified as good candidates for APBI - "low risk group", 203 (32%) as possible candidates for APBI - "intermediate risk group", with no patients being in the "high risk group". Using ESTRO criteria for subgrouping of patients, the cumulative incidence of local recurrence at 10 years was 3.5% versus 4.4% (p = 0.55) in the "low risk group" and "intermediate risk group", respectively; difference 0.9% (95%CI: -2.6 to 4.5%). Furthermore, 10-year disease-free survival was 81.0% versus 86.4% (p = 0.11) in the "low" and "intermediate" risk group, respectively. The 10-year results in patients treated with breast conserving surgery followed by APBI using multicatheter brachytherapy are comparable as well between "low risk" and "intermediate risk" groups according to GEC-ESTRO criteria as between "suitable" and "cautionary" risk groups according to ASTRO criteria. Based on the present long-term results of APBI, refinement of available recommendations for APBI patient selection criteria should be discussed to allow more patients to be treated with APBI after breast conserving surgery. [ABSTRACT FROM AUTHOR]

The study explored the relationship between breast density, compressed breast thickness (CBT) in mammography (MMG) before surgery, and setup errors of the tumor bed after breast-conserving surgery (BCS). The objective was to determine which patients are likely to experience large setup errors under partial breast irradiation (PBI) for early-stage breast cancer. This study included 66 patients who underwent whole breast irradiation (42.56 Gy/16 Fr) using a general Linac with a six-axial moving couch from April to December 2023. Additionally, these cases had MMG taken preoperatively. Two qualified radiographers classified MMG as dense (extremely dense and heterogeneously dense) and non-dense (scattered and fatty). CBT cases of ≥43.5 mm and <43.5 mm were classified as high (H) and low (L), respectively. The position of each clip placed at the surgical cavity wall (2–6 for each patient, 255 clips for all patients) was determined relative to the rib using cone beam computed tomography (a total of 262 data sets of 1, 2, 9, and 16 Fr), and the vector lengths were calculated. The root mean square (RMS) of all clips in each Fr (RMSfr) was calculated, and the course of the variation between each Fr was assessed. Furthermore, the RMS of RMSfr (RMSall) was calculated for all cases. Cases were categorized as dense or non-dense and CBT-H or CBT-L; multiple comparison tests for the median RMSfr and RMSall were conducted using Bonferroni's correction. The median RMSalls of the dense_CBT-L, dense_CBT-H, non-dense_CBT-L, and non-dense_CBT-H groups were 3.6, 4.0, 3.3, and 5.0 mm, respectively. The median RMSall difference between the CBT-H and CBT-L groups was 0.6 mm, whereas non-dense_CBH_H, including the distinction of breast density, increased to >1.0 mm compared with the other groups. Multiple comparison tests revealed a significant difference in the median RMSalls among the four groups (p -value = 0.0065). The table shows the number of cases and the statistics of the four RMSfr for groups in each fraction. The p -values of the combination of CBT and breast density for 1, 2, 9, and 16 Fr were 0.98, 0.71, 0.15, and 0.06, respectively. The median RMSfr in the non-dense_CBT-H group was larger than that in the other groups, which increased from 3.0 to 5.4 mm with increasing fractions. Additionally, the median RMSfr in 16 Fr was the highest at 5.4 mm, which is 1.6 mm higher than the other groups. Errors in the tumor bed setup for PBI after BCS are more pronounced in large and non-dense breasts on MMG. [ABSTRACT FROM AUTHOR]

Image-based mnemonic resources, such as SketchyMedical©, have become popular in medical education and use the "method of loci" memorization technique to effectively promote retention. We used AI image generators to create a similar platform for radiation oncology (RO). Here we report the results of our survey evaluating residents' opinions of the platform. Five images were generated using the AI software DALL-E© and Midjourney© and refined with editing software. The mnemonics symbolized the RAPIDO and UK Fast Forward trials, treatment eligibility for accelerated partial breast irradiation, OAR constraints for conventional CNS and H&N treatments, and low energy photon interactions. A 15-question survey was made using a 5-point Likert Scale and sent to 648 PGY1-5 RO residents to assess educational experience and perceived usefulness of the mnemonics. 41 responses were recorded. Median age was 31 (IQR = 4) years. Training level comprised of 2.4% PGY1, 24.4% PGY2, 19.5% PGY3, 31.7% PGY4, and 22.0% PGY5. Full results are shown in Table 1. All respondents were familiar with image-based mnemonics and 82.9% used them in medical school. Respondents strongly or somewhat agreed that memorizing details related to clinical trials (87.8%), treatment regimens (87.8%), OAR constraints (87.8%), and physics concepts (82.9%) is time-consuming. They found the mnemonics helpful for learning clinical trials (70.7%), treatment regimens (70.7%), OAR constraints (63.4%), and physics concepts (58.5%). Most (87.8%) wished this platform previously existed, and 65.9% could envision using it. 58.5% felt the detail in the mnemonics was sufficient and 92.7% felt they were most useful when accompanied by a story. 53.7% could see themselves contributing to our platform. Written feedback suggested decreasing text and adding consistent symbols across images. Our findings strongly suggest residents in radiation oncology endorse the efficacy of AI image-based mnemonics and express a desire for their integration into educational frameworks. [ABSTRACT FROM AUTHOR]

Accelerated partial breast irradiation (APBI) and hypofractionated partial breast irradiation (PBI) have emerged as alternative treatments to whole breast irradiation (WBI) for many patients with early breast cancer (BC) based on randomized clinical trials involving > 10,000 patients. As trial data matured, many societies, including the American Society for Radiation Oncology, issued consensus statements regarding suitability of patients for APBI or PBI (A/PBI). However, there are few data regarding utilization of A/PBI in patients with early BC. We examine the National Cancer Database (NCDB) to evaluate the hypothesis that A/PBI use has increased over time but is still used in a minority of patients. Within the NCDB, we identified patients who underwent margin-negative breast conserving surgery and adjuvant radiation therapy in the years 2010-2021 with the following favorable criteria: hormone-receptor positive/human epidermal growth factor receptor 2 negative (HR+/HER2-); age ≥50 yr; pathologic T1N0; grade 1-2; non-lobular histology; no neoadjuvant systemic therapy use. Patients with missing dosimetry data, those coded as receiving total dose > 66Gy and/or > 36 fractions (Fx), and/or dose groups in which fewer than 250 patients were treated were excluded from analysis. We further classified by type of APBI/PBI technique: external beam (EB-APBI), brachytherapy (Brachy), intraoperative radiation therapy (IORT), or hypofractionated external beam PBI (EB-PBI). We used the following definitions:18Gy/1Fx or 34Gy/10Fx (Brachy); 20Gy in 1Fx or 21Gy/1Fx (IORT); 30Gy/5Fx or 38.5Gy/10Fx (EB-APBI) From 2018-2021, patients that received 40-40.5Gy/15Fx and coded as having received PBI were classified as EB-PBI. All others WBI. Chi-Square test is used to evaluate trends in A/PBI use. Of an initial 3,956,621 patients in the NCDB, 317,437 patients met the eligibility criteria and 242,817 had complete radiation dosimetry data. In this cohort, 25,973(10.7%) received A/PBI, while 216,844(89.3%) underwent WBI. Among patients that underwent A/PBI, 36.7% received EB-APBI, 32% brachy, 20.5% IORT, and 10.7% EB-PBI. The use for A/PBI increased from 8.0% (2010-2017) to 13.7% (2018-2021) (p<0.001). The use of 30Gy/5Fx EB-APBI also increased significantly from 512(1.7%) in 2019 to 2,672(8.8%) in 2021 (p<0.001). In the final year, among the 30,346 patients analyzed, 5444(17.9%) received any form of A/PBI and 3,213(10.6%) were treated with either 30Gy/5Fx EB-APBI or brachy. Over the past decade there has been a significant rise in A/PBI use in patients with low-risk HR+/HER2- BC. Despite the increasing trend, even in the most recent year, less than one in five potentially eligible patients receive A/PBI. Further, among patients treated in 2021, only one in ten patients receive 30Gy/5Fx EB-APBI or brachytherapy, two forms of APBI which possess the combination of similar cancer control outcomes, greater convenience and less toxicity compared to WBI. [ABSTRACT FROM AUTHOR]

Accelerated Partial Breast Irradiation (APBI) with external beam IMRT has emerged as an excellent treatment strategy for select early-stage breast cancer patients. Our institutional preference for APBI consists of 3000cGy in 5 non-consecutive fractions with IMRT per the Florence protocol. At our institution, this has recently evolved to include deep-inspiration breath-hold (DIBH) for motion management, along with the preferred use of radiopaque filament marker (FM) for target delineation and daily CBCT-based image guidance. The CTV to PTV margin has been reduced from 10-mm to 5-mm for such patients, in light of reduction in uncertainty of target localization and uncertainty of motion. We hypothesize a reduction in CTV-to-PTV margins from 10 mm to 5 mm with implementation of DIBH and filament marker for IMRT-based APBI will result in non-inferior local control compared to recently published contemporary data. This study was conducted through a retrospective chart review of 16 stage 0 and 57 stage 1 breast cancer patients including 60 "acceptable" and 13 "cautionary" patients per ASTRO APBI consensus guidelines treated at our institution from March 2021 through June 2023 with 5-fraction IMRT APBI, using DIBH for motion management and lumpectomy cavity delineation using a FM. Standard 10-mm margin was used to expand from lumpectomy cavity to CTV for all patients. A reduced 5-mm expansion from CTV to PTV was utilized (compared to 10-mm CTV to PTV expansion in Florence protocol) in light of motion management and target localization techniques described above. Cropping of PTV from skin surface and/or chest wall followed Florence guidelines. With a median follow up of 23.1 months, local control was 100% for patients treated with reduced 5-mm CTV to PTV margins. There were no cases of subacute radiation pneumonitis. Compared to the results of "standard" 10-mm CTV to PTV expansion, the use of 5-mm CTV to PTV margin reduced the mean PTV for these patients by approximately 112 cc (> 80% absolute volume reduction). For patients treated with 5-fraction external beam APBI, the use of DIBH for motion management and filament marker for target localization appears to allow for safe reduction in CTV-to-PTV expansion without reduction in local control. Absolute reduction in PTV with this approach is substantial, with potential implications for cosmetic outcome or other late effects. Longer term follow up will be needed to confirm the durability of these local control and toxicity results and may offer potential for improved cosmesis results. [ABSTRACT FROM AUTHOR]

To evaluate the risk factors associated with the long-term adverse cosmesis, cosmetic deterioration and breast induration in the patients after breast-conserving surgery (BCS) and whole breast irradiation (WBI). This post hoc analysis was performed using data of 614 patients from a phase III, randomized controlled trial comparing hypofractionated radiotherapy (HFRT, WBI at 43.5 Gy in 15 fractions followed by a tumor-bed boost at 8.7 Gy in 3 fractions over 3.5 weeks) with conventional fractionated radiotherapy (CFRT, 50 Gy in 25 fractions followed by 10 Gy in 5 fractions over 6 weeks) after BCS. The patients who had cosmesis results at both baseline and the most recent follow-up were eligible. The endpoints included adverse cosmesis, deterioration of cosmesis and induration. The adverse cosmesis was defined as fair or poor cosmesis based on Harvard 4-scale system. The breast size (CTV volume), boost size and dosimetric parameters of heterogeneity (PTV V 105% , V 107% , V 110% and D 2cc) were collected, and their relative and absolute subjects were both recorded. Logistic regression models were used to assess the relationship between risk factors and these outcomes. The optimal cut-off values of dosimetric parameters were determined using receiver operating characteristic curve (ROC) analyses combined with the optimum Youden index. The clinicopathologic characteristics and dosimetric parameters were comparable between HFRT (n = 311) and CFRT (n = 303) groups. All patients received a tumor-bed boost after WBI; 21 (3.4%) received supra/infraclavicular nodal irradiation, and one of them received axillary nodal irradiation. With the median follow-up of 110.1 months (IQR: 97.5-127.1 months), 68 (11.7%) patients developed adverse cosmesis, 65 (10.6%) had cosmetic deterioration and 50 (8.1%) had breast induration. The incidence of breast adverse effects was similar in HFRT and CFRT groups. The variables including BMI, diabetes, hormonal therapy, adjuvant chemotherapy, surgery to radiotherapy interval, adverse baseline cosmesis, CTV volume, relative PTV V 105% , absolute PTV V 107% , relative boost size, and absolute boost size were included in the multivariable analysis. The results showed that the factors associated with adverse cosmesis were adverse baseline cosmesis and relative boost size ≥ 17.2%; the factors associated with cosmetic deterioration was larger relative boost size; and the factors associated with induration was larger absolute boost size. However, the CTV volume, PTV V 105% , PTV V 107% were not independently associated with the adverse effects. For the patients receiving WBI and tumor-bed boost, the relative or absolute boost size was associated with adverse cosmesis, cosmetic deterioration and breast induration. However, the breast size and dosimetric parameters of dose heterogeneity were not identified to be independently associated with the adverse effects in this study. [ABSTRACT FROM AUTHOR]