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Patterns of radiotherapy for early breast cancer in Northern Italy compared with European and national standards
Radiotherapy and Oncology 51 (1999) 79±85
Patterns of radiotherapy for early breast cancer in Northern Italy compared with European and national standards Riccardo Valdagni a,*, Maurizio Amichetti b, Mario Ciocca a a
b
Department of Radiation Oncology, Casa di Cura S.Pio X, via F. Nava 31, 20159 Milan, Italy Department of Radiation Oncology, Ospedale S.Chiara, Largo Medaglie d'Oro 3, 38100 Trento, Italy Received 13 August 1998; received in revised form 16 December 1998; accepted 8 January 1999
Abstract Purpose: To assess the current practice of early breast cancer (EBC) post-operative irradiation in Northern Italy and to evaluate its conformance with European standards and recently de®ned national guidelines. Materials and methods: Fifty Radiotherapy departments in Northern Italy received a questionnaire assessing parameters on pre-treatment evaluation of patients, on preparation, prescription and execution phases of irradiation (XRT), on surgery-XRT-chemotherapy integration and on follow-up. The analysis of collected information was compared with both the 1991 EORTC-EUSOMA guidelines and the 1997 AIRO (Italian Association for Radiation Oncology) minimal requirements on EBC post-operative irradiation. Results: Thirty-nine out of 50 (78%) departments answered the questionnaire. All treat T1-T2 tumours, after tumourectomy or, mostly, quadrantectomy. The mean interval between surgery and XRT is 45 ^ 14 days. Chemotherapy is delivered concurrently in 70% of departments, CTV is represented by residual mammary gland in 100% of cases, while 38% and 52% of departments occasionally treat internal mammary and axillary or supra-clavicular nodes, respectively. Total dose delivered to the whole breast is 46-50 Gy in 98% (1.8-2 Gy/ fraction). The tumour bed is boosted in 79% of cases. An immobilization device is used in 28%.of cases CTV is clinically localized in 62% of patients. Tangential ®elds are simulated in 85% of centres, with ®lm storage in 78% of cases. Co±60 units are used in 58% and/or 4-6 MV Xrays in 70% of centres, mostly utilizing beam modi®ers. Computerized treatment planning is performed in 95% of cases. Fifty-®ve percent of departments prescribe the dose at the ICRU point. Portal ®lms are routinely taken in 50% of cases. Boost irradiation is mainly performed using external XRT. Lastly, acute and late side effects and cosmesis are respectively evaluated in 100%, 98% and 90% of centres. Conclusions: Results on current practice in Northern Italy generally show a good conformance with European standards. However, some variables related to treatment prescription, simulation and treatment planning need to be standardized. This set of information was largely utilized by the AIRO to de®ne national guidelines adapted to the Italian resources and situation. q 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Keywords: Radiotherapy; Early breast cancer; Current practice survey
1. Introduction Several prospective randomized trials and large retrospective series have clearly established that breast conserving surgery plus post-operative irradiation is the standard of care in the treatment of early-stage breast cancer (EBC) [25]. The rising role of breast conservation therapy in EBC has led to an increased use of radiation therapy following conservative surgery [9,10,27]. Currently, breast irradiation is one of the most common practices in radiation oncology departments in Italy and represents approximately 25% of treatments yearly delivered [1]. The irregularly conical morphology of the mammary
gland and the inclusion of critical tissues in the treated volume make breast irradiation a technically complex procedure [8]. It is well known that radiation therapy techniques for this site have been developed by individual Institutions; pre-treatment evaluation, treatment preparation and execution phases have been optimized according to the chosen approach [2,7,11,16,21,23,26,30,31,32]. Nonetheless, the need to homogenize such a treatment technique is only partially supported by widely recognized standardized criteria: few documents based on the best scienti®c evidence suggest to adopt minimum requirements as standard of care [4,12,36]. Studies of radiotherapy patterns of care provide information on current clinical practice and make it possible to evaluate the appropriateness and the quality of medical care; they also contribute to the development of guidelines
* Corresponding author. 0167-8140/99/$ - see front matter q 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0167-814 0(99)00028-6
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3. Results
Table 1 Summary of the survey structure Section
Number of questions
Number of choices of answers
Range of answers/ item
1. 2. 3. 4.
12 6 20 3
38 31 110 14
2±6 1±14 2±13 2±7
9 3
50 8
2±17 1±5
4
16
2±9
Pre-treatment evaluation Treatment prescription Treatment preparation Treatment execution and veri®cation 5. Tumour bed irradiation 6. Treatment integration with surgery and chemotherapy 7. Toxicity and cosmesis evaluation
and ®nally help planning the correct utilisation of available resources. This investigation was aimed at assessing the pro®le and current quality of Radiation Oncology practice in EBC postoperative irradiation in a group of North-Italian Institutions. Secondary endpoints of this report are the identi®cation of areas of clinical practice needing improvements and the comparison of the present process of irradiation with European and Italian recommendations.
2. Materials and methods This study, performed under the patronage of the Italian Association for Radiation Oncology (AIRO), was conceived by the three authors in the form of a questionnaire. The document draft was preliminarly revised by three Italian radiation oncologists working in the ®eld of breast cancer. The questionnaire was composed of speci®c questions in a multiple choice format and concerned locally adopted clinical and radiation parameters. It consisted of seven sections: (1) pre-treatment evaluation, (2) treatment prescription, (3) treatment preparation, (4) treatment execution and veri®cation, (5) tumour bed irradiation, (6) treatment integration with other modalities, (7) toxicity and cosmesis evaluation (Table 1). In order to characterize the current practice of EBC irradiation, 57 questions were asked with an average of 1-17 choices each (267 in all), in most cases, choices were not mutually exclusive. In March 1996, the questionnaire was sent to all 50 radiation oncology departments in Northern Italy. The surveyed regions included Piemonte, Liguria, Lombardia, Veneto, Trentino-Alto Adige, Friuli VeneziaGiulia, Emilia Romagna, globally accounting for about 25 milions inhabitants. Results were compared with both European (EORTCEUSOMA) [4] and recently de®ned Italian (AIRO) standards [34]. Data dispersion was expressed by a range of values and the standard deviation (SD).
Data were collected from 39 out of 50 (78%) completed questionnaires. About 5,700 EBC patients/year are treated in these departments, with a mean of 145 patients treated/ year (range: 25-590, SD: 102), representing approximately 40% of the total EBC patients treated yearly in Italy [1]. Only items relevant to the radiotherapy aspects of EBC treatments are reported in detail; other related ®ndings such as treatments of bilateral tumours, potential biological factors in¯uencing treatment strategy, etc., are not reported in this analysis. 3.1. Pre-treatment evaluation All departments treat T1 and T2 tumours, with a maximum accepted pathological diameter of 3 cm in 80% of cases (20%: diameter ,5 cm). Four centres (8%) adopt age limit, where only patients younger than 75±85 years are treated. Quadrantectomy is the most frequent surgical approach (85%); tumourectomy or wide excision is performed in 15% of cases. Axillary dissection is routinely performed in all departments and limited to the ®rst level in 10%. The presence of extensive intra-ductal component does not modify the therapeutic approach in the majority of departments (72%), while the presence of positive margins of excision in¯uences the treatment strategy in 88% of departments. Requested pre-XRT staging procedures are the following: chest X-ray (100% of cases), bone scan (95%), liver ultrasonography (93%). Post-surgery mammograms are only occasionally performed in 40% of centres, and routinely requested in 10%. 3.2. Treatment prescription 3.2.1. De®nition of clinical target volume (CTV) CTV is represented by the residual mammary gland in 100% of cases. No departments routinely treat internal mammary, axillary or supra-clavicular nodes; with respect to tumour, patient and surgery related factors [34], lymph nodes are occasionally treated as follows: 38% of centres irradiate internal mammary nodes and 52% the axilla or the supra-clavicular fossa. The skin overlying the mammary gland is usually or occasionally considered part of CTV in 10% and 18% of departments, respectively. 3.2.2. Dose prescription Data regarding total radiation dose delivered to the whole breast show a narrow distribution: all prescribe total doses in the range of 46 to 52 Gy, while 90% of departments prescribe 50 Gy. Conventional fractionation of 2 Gy/fraction is used in 100% of cases; occasionally, different fraction sizes are utilized (1.8 Gy and 2.3 Gy in 10% and 2% of cases, respectively). Boost irradiation is prescribed by the majority of centres
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Table 2 Comparison of main variables in EBC irradiation: current practice in Northern Italy (present study) versus Italian guidelines [34] versus European guidelines [4]. Variables have been grouped with respect to the following phases, (a) pre-treatment evaluation (b) whole breast treatment prescription and preparation (c) treatment veri®cation, toxicity and cosmesis evaluation and tumour bed irradiation
(a) Pre-treatment evaluation staging Chest X-rays Bone scan Liver ultra-sonography Post-surgery mammogram Time interval between surgery and XRT (days)
Current practice in northern italy
Italian guidelines
European guidelines
100% 95% 93% 50% 45 ^ 14 (1 SD)
Yes Yes Yes Yes <60
Not speci®ed Not speci®ed Not speci®ed Not speci®ed Not speci®ed
Yes Yes L2: yes Yes
Yes Yes Not speci®ed Yes
L2: yes
L2: yes
Yes No L2: yes L1: 1±2 cm L2: individual a
Yes No No Not speci®ed
98% 100% b
Yes Yes
Yes Yes
100% 85% 50%
Yes Yes Yes
Yes Yes Yes
<3 cm: 78%
<3 cm
<3 cm
58%
Yes
Yes
90% 88%
Yes Yes
Yes Yes
95% 70% 55%
Yes L2: yes Yes
Yes L2: yes Yes
< 15%:80% no limits: 20% 93%
L1: < 15% L2: < 10% Yes
<15% Yes
100%
Yes c
Yes c
88%
Yes
Yes
10%
No d
No d
Yes L2: yes Yes Yes Not speci®ed Yes
Yes L2: yes Not speci®ed Not speci®ed Not speci®ed Yes
Yes
Yes
(b) Whole breast irradiation: treatment prescription and preparation Patient position Supine 100% Arm holder 40% Immobilisation device 28% Patient data acquisition 75% Central plane > Three planes 68% CTV localization Palpation 62% Anatomy landmarks 2% CT scans 38% Ideal margins 0.5±2 cm: 59% individual: 40% Dose prescription 45±50 Gy 1.8±2 Gy/fraction Irradiation technique Tangential beams Treatment simulation Dorsal beam edge alignment Maximum central lung distance, (CLD) Simulator ®lms for all ®elds Patient alignment by lasers Patient skin marks Dose distribution Computer calculation Lung density correction Dose prescription at ICRU point Dose inhomogeneity accepted Determination of minimum and maximum doses Beam quality: Co-60 or X-ray beams (<6 MV) Wedge ®lters or tissue compensators Skin bolus
(c) Treatment veri®cation, toxicity and cosmesis evaluation, tumour bed irradiation Treatment veri®cation Portal imaging 50% In vivo dosimetry 18% Acute side effect valuation 100% Late side effect evaluation 98% Cosmetic evaluation 90% Tumour bed irradiation 79% Dose prescription 15±25 Gy 100% among 79%
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Table 2 (continued)
(a) Pre-treatment evaluation staging 1.8±2 Gy/fraction Target volume localisation Diagnostic imaging Scar Patient information Surgery information
Current practice in northern italy
Italian guidelines
European guidelines
100% among 79%
Yes
Not speci®ed
45% 90% 23% 45%
Yes Yes Yes Yes
Yes Yes Yes Yes
a
L2, desirable treatment level; L1, minimum requirements. Occasionally, 2.3 Gy/fraction in 2% of centres. c Co-60 beams adequate for breast with dorsal beam edge separation < 20 cm. d Unless skin involved. b
(78%). Ninety-seven percent of them utilize external beams at a total dose of 10 Gy (97% of cases), while doses up to 20 Gy are commonly or occasionally delivered in 23% of them. Dose/fraction is 2 Gy in 100% of cases, occasionally 2.5 and 3 Gy in 16% and 3% of cases respectively. Brachytherapy is applied in a small percentage of departments (8%) at a total dose of 15 to 20 Gy. 3.3. Treatment preparation 3.3.1. Treatment position All centres treat patients in supine position, using a perpendicular arm holder in 40% of cases and with the ipsilateral arm above the head in 60% of cases. Table wedge is routinely or occasionally utilized in 50% of departments. 3.3.2. Patient immobilisation In 72% of departments, no immobilisation system is used, while 23% of centres utilize individualized devices (alfacradle cast in 12% of cases, vacuum-formed cellulose acetate cast in 8%). 3.3.3. Localisation of the CTV and determination of the planning target volume (PTV) Most of the departments (62%) localize residual mammary glands using anatomical landmarks and/or palpation. CT is used exclusively or in addition to clinical methods in 15 (38%) or 28 (72%) out of 39 centres, respectively. In one case (3%), ultra-sonography is used in addition to clinical methods. Ideal margins to be added to CTV to determine PTV are individualized in 40% of centres; ®xed, non-individualized margins of 0.5-2 cm are employed in 59% of cases (1 cm: 52%). 3.3.4. Simulation Eighty-®ve percent of departments simulate the treatment, while the remaining 15% determine treatment ®eld directions and port sizes directly on the treatment unit. Globally, a conventional simulator is used in 78% of cases; in 12% a CT-simulation is performed, using a CT-
simulator or a CT scanner combined with an independent, automatic treatment planning system (TPS). Skin tattoos are used in 88% of cases. Simulation ®lms are stored by 78% of departments (26%: one ®lm, 74%: both ®lms). 3.3.5. Irradiation technique In all centres, the basic technique consists of two opposed tangential ®elds. An isocentric technique is used in 60% of cases, while an SSD technique is applied in the other. Treatments are delivered using a Co-60 tele-therapy unit in 58% of cases and/or using a 4-6 MV linear accelerator in 70% of cases. 3.3.6. Beam modi®ers Beam modi®ers are routinely prescribed in 88% of cases to plan a more uniform dose distribution in the CTV. In particular, most of departments use wedge ®lters, individualized tissue compensators (Ellis ®lters) are used in 5% of cases. Skin bolus is used in 10% of cases. Individualized beam blocks are prepared in 7% of centres. 3.3.7. Methods to remove beam divergence In order to minimize irradiation to critical organs and/or to optimize adjacent ®eld junctions, several methods, applied alone or in combination, are used in 50% of centres. Methods are the following: couch isocentric rotation in 10% of cases, non-coplanar beams in 20%, half-beam block in 28% and asymmetric collimation in 12%. No strategy to remove beam divergence is used in 50% of departments. Lung tissue included in the PTV is limited to <3 cm (central lung distance: CLD [5]) in 78% of centres. No limitation to lung irradiation is applied in 22% of departments. 3.3.8. Treatment planning Patient anatomical data acquired for treatment planning consist of manual measurement of breast thickness along central axis in 25% of cases, manual determination of breast contour using mechanical devices in 20% and CT slices in 83%. An individualized treatment plan is performed in 95% of departments, utilising an automatic TPS. Inhomogeneity
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correction is routinely applied in 70% of centres. Minimum and maximum doses are recorded in the central plane in 60% of departments and in more than one plane in 38%, routinely or occasionally. Maximum doses at organs at risk are recorded in 48% of departments. No limitations in dose inhomogeneity inside the PTV are prede®ned in 20% of cases, while a difference between maximum and minimum dose of , 15% is generally accepted in the remaining. Dosage is prescribed at the ICRU point [15] in 55% of centres, at the level of 95% isodose in 25% and at the minimum dose inside the PTV in 10%, while 10% of centres did not answer that question. Treatment time or monitor units are calculated manually in 10% of cases and automatically in 90%. 3.4. Treatment execution and veri®cation Patient alignment is veri®ed using lasers in 90% of departments. Portal ®lms are routinely taken at least once in 50% of centres, usually at the ®rst session; sequential portal imaging is made on a regular basis during the treatment course in 15% of cases. On-line portal imaging is available in 7% of departments. In vivo dosimetry is occasionally performed in 18% of centres. 3.5. Tumor bed irradiation Among the 31 departments (79%) which boost the tumour bed, information required to determine tumor location is derived from scar position (90% of cases) and/or surgical records (45%) and/or a patient's description (23%) and/or a pre-surgical mammogram (45%) and/or post-surgery imaging techniques (19%). Boost dose is delivered with external beam techniques (electrons: 87%, orthovoltage: 48%, high-energy photons: 13%). Brachytherapy is occasionally utilized in 10% (3/31) of centres boosting the tumour bed (50% peri-operative and 50% post-operative). In 71% of cases, no simulation is routinely performed, while a conventional simulator is routinely or occasionally utilized in 42%. Patient anatomical data collected for treatment planning consist of CT-slices in 45% of cases, ultrasonography examinations in 3%, clinical estimation of breast thickness in 74%. A computerized treatment plan is performed in 39% of cases, applying inhomogeneity corrections in 13%. Treatment time or monitor units are calculated manually in 45% of departments and automatically in 65%. Dosage is prescribed at ICRU point in 32% of cases, at the level of 80 to 95% isodoses in 32%, at the minimum dose inside the PTV in 10%, at the maximum dose in 35%. Individualized shielding blocks and skin bolus are used in 29% and 23% of departments respectively. In vivo dosimetry is occasionally performed in one Centre (3%). 3.6. Treatment integration with surgery and chemotherapy An interval of 45 ^ 14 days elapses between surgery and
83
XRT (range: 25±75 days). In particular, more than 30 days are needed to start XRT in 77% of centres. Adjuvant chemotherapy is delivered concurrently with XRT in 70% of departments, a sandwich integration (i.e. chemotherapyXRT-chemotherapy) is used in 12% and a sequential approach in 65% (chemotherapy before XRT: 25%; chemotherapy after XRT: 40%). It must be noted that these approaches are not mutually exclusive in the intradepartment population. 3.7. Toxicity and cosmesis evaluation Acute and late side effects are recorded in 100% and 98% of departments respectively. RTOG/EORTC scoring criteria are used in 55% of centres. A subjective, cosmetic evaluation is performed in 90% of departments,it is based on radiation oncologist's opinion in all cases and also on patient interrogation in 42%. An objective evaluation is performed in 12% of centres, using different cosmetic score systems. 4. Discussion This survey was carried on to de®ne the state of practice in Radiation Oncology in the ®eld of post-operative irradiation of EBC, to determine areas where de®ciencies exist and to constitute a base of reference to assess improvement over time. Data was collected from a sample of Institutions reasonably representing the Northern Italian situation, to determine multi-regional patterns of irradiation and compliance with European and recently de®ned Italian guidelines [4,34]. It should be noted that this study has been potentially limited by the fact that 11 centres (22%) did not return the questionnaire as well as by the method chosen to collect data, which did not imply on-site visits [17]. In Table 2, main variables currently adopted in Northern Italy in EBC irradiation are summarized and compared with Italian and European guidelines. From the analysis of this survey it appears that generally there is good conformance with international standards [4,12] with respect to basic treatment technique and doses. However, several variables need to be standardized, particularly when speci®c aspects of treatment prescription, treatment planning and doses are considered. All departments should adopt conventional simulation and treatment documentation by means of simulator ®lms for all ®elds, which are currently assessed by 85% and 58% of centres respectively. With respect to beam modi®ers, most centres routinely improve dose homogeneity mainly through wedge ®lters, while only 50% try to reduce or remove beam divergence with adequate techniques. This value is inferior to that observed in the US [17], where a similar rate is reported only for free-standing facilities (60%). As mentioned before, CTV localisation methods for whole breast irradiation are correctly applied in most
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centres, although 10% of departments improperly consider the skin as part of CTV. Tumour bed is localized using different information, through not always properly combined, most departments still utilize scar as a main indicator for tumour bed location, although modern surgical procedures determine surgical incision also considering its cosmetic impact. Nonetheless, no de®ned recommendations are given on this issue in the literature and several conventional empirical and radiological methods are suggested to localize the surgical bed, these are subcutaneous induration, scar position, pre- or post-surgical mammograms, ultrasound and CT, surgical clips, etc. [13,19,20,22,28,29,33]. It should be also noted that this study has shown that 10% of centres apply skin boluses, although they are generally neither needed nor recommended [17,31]. When treatment units are evaluated, it can be observed that tele-cobalt therapy units are still largely used (58% of centres): this is probably due to the relatively old age of treatment machines operating in Italy, where 60% of units are more than 10 years old [6]. When treating large breasts, this ®nding should be considered a structural element of de®ciency and should be modi®ed in the context of both high cutaneous and subcutaneous dose delivered with gamma rays and large tissue inhomogeneities [2,14]. As widely recognized, ideal dose distribution in the target volume should be as homogeneous as possible in order to achieve a uniform biological effect in the breast, thus avoiding hot spots which may lead to breast shrinkage and poor cosmesis. In the context of treatment outcome, sub-optimal dosimetry could play a relevant role, to be further investigated [24]. Similarly to the American survey [17], boost techniques are predominantly carried out with electrons, although ortho-voltage X-rays are still frequently used (48%). Wide variation among participating centres has been found in treatment planning phases: maximum and minimum doses at central plane and maximum doses at organs at risk are only registered in 60% and 48% of departments, respectively. The use of dose prescription following the ICRU recommendations is still limited to 55% of centres. The choice of prescription point varies depending on physicians, Institutions and treatment protocols [7,35]. The wide variation of dose prescription modality found in this investigation clearly appears in disagreement with ICRU report 29 and the more recent report 50 and this should be corrected. As a matter of fact, ICRU report 50 recommends that the reference point for dose speci®cation is located ®rstly in the central part of the PTV and secondly, where applicable, on/near the central axis of the beams; in breast treatment, when asymmetric jaws or half-beam blocks are utilized, the ®rst criterion should be adopted [15]. In the current international and national context, where great attention is devoted to quality assurance [3,4,18], the use of portal ®lms (50%) appears limited in comparison with the US data (97%) [17]. Moreover, the value of 15% of centres performing portal ®lms at a regular basis should be undoubtedly increased, as strongly suggested in curative
treatments [18]. Similarly, in vivo dosimetry, recommended at level 2 by both European and Italian guidelines, appears to be currently performed in too limited a percentage (18%) of departments. Although several aspects of treatment process have shown a satisfactory compliance to European standards, some important deviations, mainly related to treatment planning and preparation should be optimized. These areas of lack of compliance could be corrected with staff education and with a more widespread diffusion of guidelines. Acknowledgements The authors would like to thank radiation oncologists and medical physicists of departments participating in this survey (see complete list reported below). Without their co-operation, this study could have not been performed. The authors wish also to thank Ms Tiziana Magnani for her skillful revision of the English language. List of departments of radiation oncology and physicians participating in the survey: Ospedale di Alessandria (V. Novella), C.R.O. - Aviano (L. Arcicasa and M. Roncadin), Ospedale di Belluno (S. Dal Fior), Ospedali Riuniti - Bergamo (A. Personeni), Ospedale di Biella (G. Moro), Ospedale S.Orsola Malpighi - Bologna (S. Neri), Ospedale Civile - Brescia (M. Bignardi), Ospedale S.Anna - Como (D. Cosentino), Ospedale di Cremona (B. Morrica), Ospedale di Cuneo (E.G. Russi), Ospedale S.Anna - Ferrara (P. Api), IST - Genova (V. Vitale), Ospedale di Ivrea (F. Ozzello), Ospedale di Legnago (F. Lonardi), I.E.O. - Milano (R. Orecchia), I.N.T. - Milano (R. Zucali and R. Kenda), Casa di Cura S.Pio X - Milano (C. Italia), Ospedale Ca' Granda Niguarda - Milano (B. Fanfani), Ospedale Clinicizzato - S.Donato Milanese (A. Lattuada), Ospedale Civile - Mestre (A. Michele), Ospedale S.Gerardo - Monza (S. Meregalli), Ospedale Maggiore Novara (G. Gambaro), Ospedale di Padova (A. Rigon), IRCCS S.Matteo - Pavia (P. Franchini), Ospedale Civile Ravenna (N. Minguzzi), Ospedale di Reggio Emilia (G. Zini), Ospedale di Rovigo (C. Polico and G. Mandoliti), Ospedale S. Paolo - Savona (R. Chiarlone), Ospedale di Sondrio (I. Di Lorenzo), Ospedale di Sanremo (G. Ottolenghi), Ospedale S.Giovanni Battista -Torino (G.L. Sannazzari), Ospedale S.Giovanni Vecchio - Torino (B. Sola), Ospedale S.Chiara - Trento (M. Amichetti), Ospedale di Treviso (F. Coghetto), Ospedale di Trieste (C. Vidali), Ospedale di Udine (S. Fongione), Ospedale di Circolo Varese (A. Richetti), Ospedale Civile - Venezia (S. Maluta), Ospedale di Vicenza (R.B. Guglielmi and M. Balli). References [1] AIRO document. La Radioterapia Oncologica in Italia (anno 1993). Associazione Italiana di Radioterapia Oncologica (AIRO), 1994.
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[20] Lingos TI, Harris JR. What is the optimal technique of irradiation in breast-conserving therapy?. In: Fletcher GH, Levitt SH, editors. Nondisseminated breast cancer. Controversial issues in management, Berlin: Springer, 1993. pp. 105. [21] Merchant TE, McCormick B. Prone position breast irradiation. Int. J. Radiat. Oncol. Biol. Phys. 1994;30:197±203. [22] Messer PM, Kirikuta IC, Bratengeier K, Flentje M. CT planning of boost irradiation in radiotherapy of breast cancer after conservative surgery. Radiother. Oncol. 1997;42:239±243. [23] Montague ED, Fletcher GH, Romsdahl MM, Shell SR. University of Texas, M.D. Anderson Hospital, technique for treatment of early breast cancer with conservation surgery and irradiation. In: Harris JR, Hellman S, Silen W, editors. Conservative management of breast cancer, Philadelpia PA: Lippincott Co, 1983. pp. 47. [24] Moody AM, Mayles WPM, Bliss JM, A'Hern RP, Owen JR, Regan J, Yarnold JR. The in¯uence of breast size on late radiation effects and association with radiotherapy dose inhomogeneity. Radiother. Oncol. 1994;33:106±112. [25] Morris AD, Morris RD, Wilson JF, et al. Breast-conserving therapy versus mastectomy in early-stage breast cancer: a meta-analysis of 10-year survival. Cancer J. Sci. Am. 1997;3:6±12. [26] Podgorsack EB, Gosselin M, Pla M, Kim TH. A simple iso-centric technique for irradiation of the breast, chest wall and peripheral lymphatics, Br. . J. Radiol. 1984;57:57±63. [27] Recht A. Selection of patients with early stage invasive breast cancer for treatment with conservative surgery and radiation therapy. Semin. Oncol. 1996;23:19±30. [28] Regine WF, Ayyangar KM, Komarnicky LT, Bhandare N, Mans®eld CM. Computer-CT planning of the electron boost in de®nitive breast irradiation. Int. J. Radiat. Oncol. Biol. Phys. 1991;20:121±125. [29] Solin LJ, Chu JCH, Larsen R, Fowble BL, Galvin JM, Goodman RL. Determination of Depth for electron beam boost. Int. J. Radiat. Oncol. Biol. Phys. 1987;13:1915±1919. [30] Svensson GK, Chin LM, Siddon RL, Harris JR. Breast treatment techniques at the Joint Center for Radiation Therapy. In: Harris JR, Hellman S, Silen W, editors. Conservative management of breast cancer, Philadelpia PA: Lippincott Co, 1983. pp. 47. [31] Svensson GK, Bjarngard BE, Larse RD, Levene MB. A modi®ed three ®eld technique for breast treatment, ffft. J. Radiat. Oncol. Biol. Phys. 1980;6:689±694. [32] Valdagni R, Ciocca M, Busana L, Modugno A, Italia C. Beam modi®yng devices in the treatment of early breast cancer. 3-D stepped compensating technique, Radiother. Oncol. 1992;23:192±195. [33] Valdagni R, Italia C, Montanaro P, Ciocca M, Morandi G, Salvadori B. Clinical target volume localization using conventional methods (anatomy and palpation) and ultrasonography in early breast cancer postoperative external irradiation. Radiother. Oncol. 1997;42:231± 237. [34] Valdagni R. Standard di riferimento nell'irradiazione del cancro della mammella in stadio iniziale, Documento A.I.R.O. - A.I.F.B., 1997. [35] van Bree NAM, van Battum LJ, Huizenga H, Mijnheer BJ. Threedimensional dose distribution of tangential breast treatment, a national dosimetry intercomparison, Radiother. Oncol. 1991;22:252±260. [36] Winchester D, Cox J. Standards for breast-conservation treatment. Ca Cancer J. 1992;42:134±162.
Patterns of radiotherapy for early breast cancer in Northern Italy compared with European and national standards Riccardo Valdagni a,*, Maurizio Amichetti b, Mario Ciocca a a
b
Department of Radiation Oncology, Casa di Cura S.Pio X, via F. Nava 31, 20159 Milan, Italy Department of Radiation Oncology, Ospedale S.Chiara, Largo Medaglie d'Oro 3, 38100 Trento, Italy Received 13 August 1998; received in revised form 16 December 1998; accepted 8 January 1999
Abstract Purpose: To assess the current practice of early breast cancer (EBC) post-operative irradiation in Northern Italy and to evaluate its conformance with European standards and recently de®ned national guidelines. Materials and methods: Fifty Radiotherapy departments in Northern Italy received a questionnaire assessing parameters on pre-treatment evaluation of patients, on preparation, prescription and execution phases of irradiation (XRT), on surgery-XRT-chemotherapy integration and on follow-up. The analysis of collected information was compared with both the 1991 EORTC-EUSOMA guidelines and the 1997 AIRO (Italian Association for Radiation Oncology) minimal requirements on EBC post-operative irradiation. Results: Thirty-nine out of 50 (78%) departments answered the questionnaire. All treat T1-T2 tumours, after tumourectomy or, mostly, quadrantectomy. The mean interval between surgery and XRT is 45 ^ 14 days. Chemotherapy is delivered concurrently in 70% of departments, CTV is represented by residual mammary gland in 100% of cases, while 38% and 52% of departments occasionally treat internal mammary and axillary or supra-clavicular nodes, respectively. Total dose delivered to the whole breast is 46-50 Gy in 98% (1.8-2 Gy/ fraction). The tumour bed is boosted in 79% of cases. An immobilization device is used in 28%.of cases CTV is clinically localized in 62% of patients. Tangential ®elds are simulated in 85% of centres, with ®lm storage in 78% of cases. Co±60 units are used in 58% and/or 4-6 MV Xrays in 70% of centres, mostly utilizing beam modi®ers. Computerized treatment planning is performed in 95% of cases. Fifty-®ve percent of departments prescribe the dose at the ICRU point. Portal ®lms are routinely taken in 50% of cases. Boost irradiation is mainly performed using external XRT. Lastly, acute and late side effects and cosmesis are respectively evaluated in 100%, 98% and 90% of centres. Conclusions: Results on current practice in Northern Italy generally show a good conformance with European standards. However, some variables related to treatment prescription, simulation and treatment planning need to be standardized. This set of information was largely utilized by the AIRO to de®ne national guidelines adapted to the Italian resources and situation. q 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Keywords: Radiotherapy; Early breast cancer; Current practice survey
1. Introduction Several prospective randomized trials and large retrospective series have clearly established that breast conserving surgery plus post-operative irradiation is the standard of care in the treatment of early-stage breast cancer (EBC) [25]. The rising role of breast conservation therapy in EBC has led to an increased use of radiation therapy following conservative surgery [9,10,27]. Currently, breast irradiation is one of the most common practices in radiation oncology departments in Italy and represents approximately 25% of treatments yearly delivered [1]. The irregularly conical morphology of the mammary
gland and the inclusion of critical tissues in the treated volume make breast irradiation a technically complex procedure [8]. It is well known that radiation therapy techniques for this site have been developed by individual Institutions; pre-treatment evaluation, treatment preparation and execution phases have been optimized according to the chosen approach [2,7,11,16,21,23,26,30,31,32]. Nonetheless, the need to homogenize such a treatment technique is only partially supported by widely recognized standardized criteria: few documents based on the best scienti®c evidence suggest to adopt minimum requirements as standard of care [4,12,36]. Studies of radiotherapy patterns of care provide information on current clinical practice and make it possible to evaluate the appropriateness and the quality of medical care; they also contribute to the development of guidelines
* Corresponding author. 0167-8140/99/$ - see front matter q 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0167-814 0(99)00028-6
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3. Results
Table 1 Summary of the survey structure Section
Number of questions
Number of choices of answers
Range of answers/ item
1. 2. 3. 4.
12 6 20 3
38 31 110 14
2±6 1±14 2±13 2±7
9 3
50 8
2±17 1±5
4
16
2±9
Pre-treatment evaluation Treatment prescription Treatment preparation Treatment execution and veri®cation 5. Tumour bed irradiation 6. Treatment integration with surgery and chemotherapy 7. Toxicity and cosmesis evaluation
and ®nally help planning the correct utilisation of available resources. This investigation was aimed at assessing the pro®le and current quality of Radiation Oncology practice in EBC postoperative irradiation in a group of North-Italian Institutions. Secondary endpoints of this report are the identi®cation of areas of clinical practice needing improvements and the comparison of the present process of irradiation with European and Italian recommendations.
2. Materials and methods This study, performed under the patronage of the Italian Association for Radiation Oncology (AIRO), was conceived by the three authors in the form of a questionnaire. The document draft was preliminarly revised by three Italian radiation oncologists working in the ®eld of breast cancer. The questionnaire was composed of speci®c questions in a multiple choice format and concerned locally adopted clinical and radiation parameters. It consisted of seven sections: (1) pre-treatment evaluation, (2) treatment prescription, (3) treatment preparation, (4) treatment execution and veri®cation, (5) tumour bed irradiation, (6) treatment integration with other modalities, (7) toxicity and cosmesis evaluation (Table 1). In order to characterize the current practice of EBC irradiation, 57 questions were asked with an average of 1-17 choices each (267 in all), in most cases, choices were not mutually exclusive. In March 1996, the questionnaire was sent to all 50 radiation oncology departments in Northern Italy. The surveyed regions included Piemonte, Liguria, Lombardia, Veneto, Trentino-Alto Adige, Friuli VeneziaGiulia, Emilia Romagna, globally accounting for about 25 milions inhabitants. Results were compared with both European (EORTCEUSOMA) [4] and recently de®ned Italian (AIRO) standards [34]. Data dispersion was expressed by a range of values and the standard deviation (SD).
Data were collected from 39 out of 50 (78%) completed questionnaires. About 5,700 EBC patients/year are treated in these departments, with a mean of 145 patients treated/ year (range: 25-590, SD: 102), representing approximately 40% of the total EBC patients treated yearly in Italy [1]. Only items relevant to the radiotherapy aspects of EBC treatments are reported in detail; other related ®ndings such as treatments of bilateral tumours, potential biological factors in¯uencing treatment strategy, etc., are not reported in this analysis. 3.1. Pre-treatment evaluation All departments treat T1 and T2 tumours, with a maximum accepted pathological diameter of 3 cm in 80% of cases (20%: diameter ,5 cm). Four centres (8%) adopt age limit, where only patients younger than 75±85 years are treated. Quadrantectomy is the most frequent surgical approach (85%); tumourectomy or wide excision is performed in 15% of cases. Axillary dissection is routinely performed in all departments and limited to the ®rst level in 10%. The presence of extensive intra-ductal component does not modify the therapeutic approach in the majority of departments (72%), while the presence of positive margins of excision in¯uences the treatment strategy in 88% of departments. Requested pre-XRT staging procedures are the following: chest X-ray (100% of cases), bone scan (95%), liver ultrasonography (93%). Post-surgery mammograms are only occasionally performed in 40% of centres, and routinely requested in 10%. 3.2. Treatment prescription 3.2.1. De®nition of clinical target volume (CTV) CTV is represented by the residual mammary gland in 100% of cases. No departments routinely treat internal mammary, axillary or supra-clavicular nodes; with respect to tumour, patient and surgery related factors [34], lymph nodes are occasionally treated as follows: 38% of centres irradiate internal mammary nodes and 52% the axilla or the supra-clavicular fossa. The skin overlying the mammary gland is usually or occasionally considered part of CTV in 10% and 18% of departments, respectively. 3.2.2. Dose prescription Data regarding total radiation dose delivered to the whole breast show a narrow distribution: all prescribe total doses in the range of 46 to 52 Gy, while 90% of departments prescribe 50 Gy. Conventional fractionation of 2 Gy/fraction is used in 100% of cases; occasionally, different fraction sizes are utilized (1.8 Gy and 2.3 Gy in 10% and 2% of cases, respectively). Boost irradiation is prescribed by the majority of centres
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Table 2 Comparison of main variables in EBC irradiation: current practice in Northern Italy (present study) versus Italian guidelines [34] versus European guidelines [4]. Variables have been grouped with respect to the following phases, (a) pre-treatment evaluation (b) whole breast treatment prescription and preparation (c) treatment veri®cation, toxicity and cosmesis evaluation and tumour bed irradiation
(a) Pre-treatment evaluation staging Chest X-rays Bone scan Liver ultra-sonography Post-surgery mammogram Time interval between surgery and XRT (days)
Current practice in northern italy
Italian guidelines
European guidelines
100% 95% 93% 50% 45 ^ 14 (1 SD)
Yes Yes Yes Yes <60
Not speci®ed Not speci®ed Not speci®ed Not speci®ed Not speci®ed
Yes Yes L2: yes Yes
Yes Yes Not speci®ed Yes
L2: yes
L2: yes
Yes No L2: yes L1: 1±2 cm L2: individual a
Yes No No Not speci®ed
98% 100% b
Yes Yes
Yes Yes
100% 85% 50%
Yes Yes Yes
Yes Yes Yes
<3 cm: 78%
<3 cm
<3 cm
58%
Yes
Yes
90% 88%
Yes Yes
Yes Yes
95% 70% 55%
Yes L2: yes Yes
Yes L2: yes Yes
< 15%:80% no limits: 20% 93%
L1: < 15% L2: < 10% Yes
<15% Yes
100%
Yes c
Yes c
88%
Yes
Yes
10%
No d
No d
Yes L2: yes Yes Yes Not speci®ed Yes
Yes L2: yes Not speci®ed Not speci®ed Not speci®ed Yes
Yes
Yes
(b) Whole breast irradiation: treatment prescription and preparation Patient position Supine 100% Arm holder 40% Immobilisation device 28% Patient data acquisition 75% Central plane > Three planes 68% CTV localization Palpation 62% Anatomy landmarks 2% CT scans 38% Ideal margins 0.5±2 cm: 59% individual: 40% Dose prescription 45±50 Gy 1.8±2 Gy/fraction Irradiation technique Tangential beams Treatment simulation Dorsal beam edge alignment Maximum central lung distance, (CLD) Simulator ®lms for all ®elds Patient alignment by lasers Patient skin marks Dose distribution Computer calculation Lung density correction Dose prescription at ICRU point Dose inhomogeneity accepted Determination of minimum and maximum doses Beam quality: Co-60 or X-ray beams (<6 MV) Wedge ®lters or tissue compensators Skin bolus
(c) Treatment veri®cation, toxicity and cosmesis evaluation, tumour bed irradiation Treatment veri®cation Portal imaging 50% In vivo dosimetry 18% Acute side effect valuation 100% Late side effect evaluation 98% Cosmetic evaluation 90% Tumour bed irradiation 79% Dose prescription 15±25 Gy 100% among 79%
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Table 2 (continued)
(a) Pre-treatment evaluation staging 1.8±2 Gy/fraction Target volume localisation Diagnostic imaging Scar Patient information Surgery information
Current practice in northern italy
Italian guidelines
European guidelines
100% among 79%
Yes
Not speci®ed
45% 90% 23% 45%
Yes Yes Yes Yes
Yes Yes Yes Yes
a
L2, desirable treatment level; L1, minimum requirements. Occasionally, 2.3 Gy/fraction in 2% of centres. c Co-60 beams adequate for breast with dorsal beam edge separation < 20 cm. d Unless skin involved. b
(78%). Ninety-seven percent of them utilize external beams at a total dose of 10 Gy (97% of cases), while doses up to 20 Gy are commonly or occasionally delivered in 23% of them. Dose/fraction is 2 Gy in 100% of cases, occasionally 2.5 and 3 Gy in 16% and 3% of cases respectively. Brachytherapy is applied in a small percentage of departments (8%) at a total dose of 15 to 20 Gy. 3.3. Treatment preparation 3.3.1. Treatment position All centres treat patients in supine position, using a perpendicular arm holder in 40% of cases and with the ipsilateral arm above the head in 60% of cases. Table wedge is routinely or occasionally utilized in 50% of departments. 3.3.2. Patient immobilisation In 72% of departments, no immobilisation system is used, while 23% of centres utilize individualized devices (alfacradle cast in 12% of cases, vacuum-formed cellulose acetate cast in 8%). 3.3.3. Localisation of the CTV and determination of the planning target volume (PTV) Most of the departments (62%) localize residual mammary glands using anatomical landmarks and/or palpation. CT is used exclusively or in addition to clinical methods in 15 (38%) or 28 (72%) out of 39 centres, respectively. In one case (3%), ultra-sonography is used in addition to clinical methods. Ideal margins to be added to CTV to determine PTV are individualized in 40% of centres; ®xed, non-individualized margins of 0.5-2 cm are employed in 59% of cases (1 cm: 52%). 3.3.4. Simulation Eighty-®ve percent of departments simulate the treatment, while the remaining 15% determine treatment ®eld directions and port sizes directly on the treatment unit. Globally, a conventional simulator is used in 78% of cases; in 12% a CT-simulation is performed, using a CT-
simulator or a CT scanner combined with an independent, automatic treatment planning system (TPS). Skin tattoos are used in 88% of cases. Simulation ®lms are stored by 78% of departments (26%: one ®lm, 74%: both ®lms). 3.3.5. Irradiation technique In all centres, the basic technique consists of two opposed tangential ®elds. An isocentric technique is used in 60% of cases, while an SSD technique is applied in the other. Treatments are delivered using a Co-60 tele-therapy unit in 58% of cases and/or using a 4-6 MV linear accelerator in 70% of cases. 3.3.6. Beam modi®ers Beam modi®ers are routinely prescribed in 88% of cases to plan a more uniform dose distribution in the CTV. In particular, most of departments use wedge ®lters, individualized tissue compensators (Ellis ®lters) are used in 5% of cases. Skin bolus is used in 10% of cases. Individualized beam blocks are prepared in 7% of centres. 3.3.7. Methods to remove beam divergence In order to minimize irradiation to critical organs and/or to optimize adjacent ®eld junctions, several methods, applied alone or in combination, are used in 50% of centres. Methods are the following: couch isocentric rotation in 10% of cases, non-coplanar beams in 20%, half-beam block in 28% and asymmetric collimation in 12%. No strategy to remove beam divergence is used in 50% of departments. Lung tissue included in the PTV is limited to <3 cm (central lung distance: CLD [5]) in 78% of centres. No limitation to lung irradiation is applied in 22% of departments. 3.3.8. Treatment planning Patient anatomical data acquired for treatment planning consist of manual measurement of breast thickness along central axis in 25% of cases, manual determination of breast contour using mechanical devices in 20% and CT slices in 83%. An individualized treatment plan is performed in 95% of departments, utilising an automatic TPS. Inhomogeneity
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correction is routinely applied in 70% of centres. Minimum and maximum doses are recorded in the central plane in 60% of departments and in more than one plane in 38%, routinely or occasionally. Maximum doses at organs at risk are recorded in 48% of departments. No limitations in dose inhomogeneity inside the PTV are prede®ned in 20% of cases, while a difference between maximum and minimum dose of , 15% is generally accepted in the remaining. Dosage is prescribed at the ICRU point [15] in 55% of centres, at the level of 95% isodose in 25% and at the minimum dose inside the PTV in 10%, while 10% of centres did not answer that question. Treatment time or monitor units are calculated manually in 10% of cases and automatically in 90%. 3.4. Treatment execution and veri®cation Patient alignment is veri®ed using lasers in 90% of departments. Portal ®lms are routinely taken at least once in 50% of centres, usually at the ®rst session; sequential portal imaging is made on a regular basis during the treatment course in 15% of cases. On-line portal imaging is available in 7% of departments. In vivo dosimetry is occasionally performed in 18% of centres. 3.5. Tumor bed irradiation Among the 31 departments (79%) which boost the tumour bed, information required to determine tumor location is derived from scar position (90% of cases) and/or surgical records (45%) and/or a patient's description (23%) and/or a pre-surgical mammogram (45%) and/or post-surgery imaging techniques (19%). Boost dose is delivered with external beam techniques (electrons: 87%, orthovoltage: 48%, high-energy photons: 13%). Brachytherapy is occasionally utilized in 10% (3/31) of centres boosting the tumour bed (50% peri-operative and 50% post-operative). In 71% of cases, no simulation is routinely performed, while a conventional simulator is routinely or occasionally utilized in 42%. Patient anatomical data collected for treatment planning consist of CT-slices in 45% of cases, ultrasonography examinations in 3%, clinical estimation of breast thickness in 74%. A computerized treatment plan is performed in 39% of cases, applying inhomogeneity corrections in 13%. Treatment time or monitor units are calculated manually in 45% of departments and automatically in 65%. Dosage is prescribed at ICRU point in 32% of cases, at the level of 80 to 95% isodoses in 32%, at the minimum dose inside the PTV in 10%, at the maximum dose in 35%. Individualized shielding blocks and skin bolus are used in 29% and 23% of departments respectively. In vivo dosimetry is occasionally performed in one Centre (3%). 3.6. Treatment integration with surgery and chemotherapy An interval of 45 ^ 14 days elapses between surgery and
83
XRT (range: 25±75 days). In particular, more than 30 days are needed to start XRT in 77% of centres. Adjuvant chemotherapy is delivered concurrently with XRT in 70% of departments, a sandwich integration (i.e. chemotherapyXRT-chemotherapy) is used in 12% and a sequential approach in 65% (chemotherapy before XRT: 25%; chemotherapy after XRT: 40%). It must be noted that these approaches are not mutually exclusive in the intradepartment population. 3.7. Toxicity and cosmesis evaluation Acute and late side effects are recorded in 100% and 98% of departments respectively. RTOG/EORTC scoring criteria are used in 55% of centres. A subjective, cosmetic evaluation is performed in 90% of departments,it is based on radiation oncologist's opinion in all cases and also on patient interrogation in 42%. An objective evaluation is performed in 12% of centres, using different cosmetic score systems. 4. Discussion This survey was carried on to de®ne the state of practice in Radiation Oncology in the ®eld of post-operative irradiation of EBC, to determine areas where de®ciencies exist and to constitute a base of reference to assess improvement over time. Data was collected from a sample of Institutions reasonably representing the Northern Italian situation, to determine multi-regional patterns of irradiation and compliance with European and recently de®ned Italian guidelines [4,34]. It should be noted that this study has been potentially limited by the fact that 11 centres (22%) did not return the questionnaire as well as by the method chosen to collect data, which did not imply on-site visits [17]. In Table 2, main variables currently adopted in Northern Italy in EBC irradiation are summarized and compared with Italian and European guidelines. From the analysis of this survey it appears that generally there is good conformance with international standards [4,12] with respect to basic treatment technique and doses. However, several variables need to be standardized, particularly when speci®c aspects of treatment prescription, treatment planning and doses are considered. All departments should adopt conventional simulation and treatment documentation by means of simulator ®lms for all ®elds, which are currently assessed by 85% and 58% of centres respectively. With respect to beam modi®ers, most centres routinely improve dose homogeneity mainly through wedge ®lters, while only 50% try to reduce or remove beam divergence with adequate techniques. This value is inferior to that observed in the US [17], where a similar rate is reported only for free-standing facilities (60%). As mentioned before, CTV localisation methods for whole breast irradiation are correctly applied in most
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centres, although 10% of departments improperly consider the skin as part of CTV. Tumour bed is localized using different information, through not always properly combined, most departments still utilize scar as a main indicator for tumour bed location, although modern surgical procedures determine surgical incision also considering its cosmetic impact. Nonetheless, no de®ned recommendations are given on this issue in the literature and several conventional empirical and radiological methods are suggested to localize the surgical bed, these are subcutaneous induration, scar position, pre- or post-surgical mammograms, ultrasound and CT, surgical clips, etc. [13,19,20,22,28,29,33]. It should be also noted that this study has shown that 10% of centres apply skin boluses, although they are generally neither needed nor recommended [17,31]. When treatment units are evaluated, it can be observed that tele-cobalt therapy units are still largely used (58% of centres): this is probably due to the relatively old age of treatment machines operating in Italy, where 60% of units are more than 10 years old [6]. When treating large breasts, this ®nding should be considered a structural element of de®ciency and should be modi®ed in the context of both high cutaneous and subcutaneous dose delivered with gamma rays and large tissue inhomogeneities [2,14]. As widely recognized, ideal dose distribution in the target volume should be as homogeneous as possible in order to achieve a uniform biological effect in the breast, thus avoiding hot spots which may lead to breast shrinkage and poor cosmesis. In the context of treatment outcome, sub-optimal dosimetry could play a relevant role, to be further investigated [24]. Similarly to the American survey [17], boost techniques are predominantly carried out with electrons, although ortho-voltage X-rays are still frequently used (48%). Wide variation among participating centres has been found in treatment planning phases: maximum and minimum doses at central plane and maximum doses at organs at risk are only registered in 60% and 48% of departments, respectively. The use of dose prescription following the ICRU recommendations is still limited to 55% of centres. The choice of prescription point varies depending on physicians, Institutions and treatment protocols [7,35]. The wide variation of dose prescription modality found in this investigation clearly appears in disagreement with ICRU report 29 and the more recent report 50 and this should be corrected. As a matter of fact, ICRU report 50 recommends that the reference point for dose speci®cation is located ®rstly in the central part of the PTV and secondly, where applicable, on/near the central axis of the beams; in breast treatment, when asymmetric jaws or half-beam blocks are utilized, the ®rst criterion should be adopted [15]. In the current international and national context, where great attention is devoted to quality assurance [3,4,18], the use of portal ®lms (50%) appears limited in comparison with the US data (97%) [17]. Moreover, the value of 15% of centres performing portal ®lms at a regular basis should be undoubtedly increased, as strongly suggested in curative
treatments [18]. Similarly, in vivo dosimetry, recommended at level 2 by both European and Italian guidelines, appears to be currently performed in too limited a percentage (18%) of departments. Although several aspects of treatment process have shown a satisfactory compliance to European standards, some important deviations, mainly related to treatment planning and preparation should be optimized. These areas of lack of compliance could be corrected with staff education and with a more widespread diffusion of guidelines. Acknowledgements The authors would like to thank radiation oncologists and medical physicists of departments participating in this survey (see complete list reported below). Without their co-operation, this study could have not been performed. The authors wish also to thank Ms Tiziana Magnani for her skillful revision of the English language. List of departments of radiation oncology and physicians participating in the survey: Ospedale di Alessandria (V. Novella), C.R.O. - Aviano (L. Arcicasa and M. Roncadin), Ospedale di Belluno (S. Dal Fior), Ospedali Riuniti - Bergamo (A. Personeni), Ospedale di Biella (G. Moro), Ospedale S.Orsola Malpighi - Bologna (S. Neri), Ospedale Civile - Brescia (M. Bignardi), Ospedale S.Anna - Como (D. Cosentino), Ospedale di Cremona (B. Morrica), Ospedale di Cuneo (E.G. Russi), Ospedale S.Anna - Ferrara (P. Api), IST - Genova (V. Vitale), Ospedale di Ivrea (F. Ozzello), Ospedale di Legnago (F. Lonardi), I.E.O. - Milano (R. Orecchia), I.N.T. - Milano (R. Zucali and R. Kenda), Casa di Cura S.Pio X - Milano (C. Italia), Ospedale Ca' Granda Niguarda - Milano (B. Fanfani), Ospedale Clinicizzato - S.Donato Milanese (A. Lattuada), Ospedale Civile - Mestre (A. Michele), Ospedale S.Gerardo - Monza (S. Meregalli), Ospedale Maggiore Novara (G. Gambaro), Ospedale di Padova (A. Rigon), IRCCS S.Matteo - Pavia (P. Franchini), Ospedale Civile Ravenna (N. Minguzzi), Ospedale di Reggio Emilia (G. Zini), Ospedale di Rovigo (C. Polico and G. Mandoliti), Ospedale S. Paolo - Savona (R. Chiarlone), Ospedale di Sondrio (I. Di Lorenzo), Ospedale di Sanremo (G. Ottolenghi), Ospedale S.Giovanni Battista -Torino (G.L. Sannazzari), Ospedale S.Giovanni Vecchio - Torino (B. Sola), Ospedale S.Chiara - Trento (M. Amichetti), Ospedale di Treviso (F. Coghetto), Ospedale di Trieste (C. Vidali), Ospedale di Udine (S. Fongione), Ospedale di Circolo Varese (A. Richetti), Ospedale Civile - Venezia (S. Maluta), Ospedale di Vicenza (R.B. Guglielmi and M. Balli). References [1] AIRO document. La Radioterapia Oncologica in Italia (anno 1993). Associazione Italiana di Radioterapia Oncologica (AIRO), 1994.
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