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Whole breast radiotherapy in the isocentric lateral decubitus position: Role of the immobilization device and table on clinical results
Cancer/Radiothérapie 23 (2019) 209–215
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Original article
Whole breast radiotherapy in the isocentric lateral decubitus position: Role of the immobilization device and table on clinical results Irradiation du sein en position latérale isocentrique : rôle de la table et des dispositifs d’immobilisation S. Krhili a , E. Costa a , H.-P. Xu a,b , Y.M. Kirova a,∗ a b
Department of Radiation Oncology, institut Curie, 26, rue d’Ulm, 75005 Paris, France Department of Radiation Oncology, Ruijin Hospital, Shangai Jiaotong University, School of Medicine, Shanghai, China
a r t i c l e
i n f o
Article history: Received 13 July 2018 Received in revised form 20 September 2018 Accepted 27 September 2018 Keywords: Breast cancer Isocentric lateral decubitus Immobilization device
a b s t r a c t Purpose. – To evaluate clinical results and the “effect bolus” based on the table design of different linear accelerators in patients with breast cancer treated by previously published whole breast irradiation in the isocentric lateral decubitus position. Material and methods. – We studied 248 consecutive female patients with early stage breast cancer treated by conservative surgery followed by three-dimensional conformal whole breast irradiation in the isocentric lateral decubitus position between January 2013 and February 2014. Radiotherapy was performed on linear accelerators using a Varian. The energy used was 4 and 10 MV photons or 6 MV photons. All patients were evaluated weekly by the radiation oncologist, acute toxicity was assessed using the NCICTC v 3.0 scale. Late toxicity and cosmetic results were evaluated 18 months after the radiotherapy. Cosmetic results were defined as excellent, good, middle or bad. Results. – Among the 248 women included, the median age was 67 years (range: 35–91 years). All received whole breast radiotherapy with boost in 144 patients (58%). One-hundred-twenty patients received normofractionated and 124 patients hypofractionated whole breast radiotherapy. Median follow-up was 18 months. Acute skin toxicity in the whole breast radiotherapy in the isocentric lateral decubitus position was acceptable: there was 47% of grade 1 radiodermatitis, 50% of grade 2 and 3% grade 3 and no grade 4 for normofractionated radiotherapy; 89% of grade 1 dermatitis and 11% of grade 2 for hypofractionated radiotherapy; 89.7% of grade 0–1 dermatitis and 10.3% of grade 2 for the “flash” scheme and did not differ between the three linear accelerators (P = 0.2, P = 0.9 and P = 0.2 respectively for the normofractionated radiotherapy, hypofractionated radiotherapy and the “flash”scheme). Late toxicity was acceptable with 84% of grade 0–1 fibrosis for normofractionated radiotherapy, 94% of patients for hypofractionated radiotherapy and 77% for “flash” scheme and did not differ between the three linear accelerators (P = 0.44, P = 1 and P = 0.22 resp.). Most of patients (81%) had an excellent or a good cosmetic outcome. Conclusions. – Whole breast radiotherapy in the isocentric lateral decubitus position is well tolerated. Clinical results are comparable based on different immobilization device allowed by linear accelerators. Particularly, there was no influence of the couch on skin tolerance and cosmetic results. ´ e´ franc¸aise de radiotherapie ´ oncologique (SFRO). Published by Elsevier Masson SAS. All © 2019 Societ rights reserved.
r é s u m é Mots clés : Cancer du sein Position latérale isocentrique Dispositifs d’immobilisation
Objectif de l’étude. – L’objectif était d’évaluer les résultats cliniques et un « effet bolus » possible de la table de différents accélérateurs linaires dans le cadre de la prise en charge avec la technique de décubitus latéral isocentrique de patientes atteintes d’un cancer du sein. Matériel et méthodes. – Nous avons étudié rétrospectivement les dossiers de 248 patientes atteintes d’un cancer du sein traité précocement avec une chirurgie conservatrice suivie par une irradiation en décubitus latéral isocentrique entre janvier 2013 et février 2014. La radiothérapie a été réalisée par accélérateurs
∗ Corresponding author. E-mail address: [email protected] (Y.M. Kirova). https://doi.org/10.1016/j.canrad.2018.09.001 ´ e´ franc¸aise de radiotherapie ´ 1278-3218/© 2019 Societ oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.
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Varian avec des énergies de photons de 4 et 10 MV et 6 MV. La toxicité aigüe a été évaluée selon les National Cancer Institute Common Toxicity Criteria (NCICTC) v 3.0. Une évaluation des résultats esthétiques (définis comme excellents, bons, moyens et mauvais) et de la toxicité tardive ont a été faite 18 mois après la fin de la radiothérapie. Résultats. – L’âge médian était de 67 ans (de 35 à 91 ans). Toutes les patients ont rec¸u une irradiation mammaire en décubitus latéral isocentrique et dans 144 cas (58 %) avec un complément au niveau du lit opératoire. Cent-vingt patientes ont rec¸u une irradiation normofractionnée et 124 hypofractionnée. Le suivi médian était de 18 mois. La toxicité précoce cutanée était acceptable, avec 47 % de cas de grade 1, 50 % de grade 2 et 3 % de grade et 0 % de grade 4 avec l’irradiation normofractionnée, 89 % de grade 1 et 11 % de grade 2 avec l’irradiation hypofractionnée, 89,7 % de grade 0–1 et 10,3 % de grade 2 avec l’irradiation en flash, sans différence entre les trois accélérateurs linéaires (respectivement p = 0,2, p = 0,9 et p = 0,2). La toxicité tardive était acceptable avec 84 % de fibroses de grade 0–1 pour la radiothérapie normofractionnée, 94 % pour celle hypofractionnée et 77 % pour le schéma “flash”, sans différence entre les trois accélérateurs linéaires (respectivement p = 0,44, p = 1 and p = 0,22). Pour une grande partie des patientes (81 %), le résultat esthétique était excellent ou bon. Conclusions. – La radiothérapie était bien tolérée et les résultats cliniques étaient comparables malgré les différences du matériel sur les différentes machines en termes de résultats esthétiques et tolérance cutanée. ´ e´ franc¸aise de radiotherapie ´ © 2019 Societ oncologique (SFRO). Publie´ par Elsevier Masson SAS. Tous ´ ´ droits reserv es.
1. Introduction After breast-conserving surgery for early breast cancer, breast irradiation decreases the rate of local recurrence significantly [1,2]. Standard breast radiation technique is tangential radiation delivered to the breast in the dorsal supine position. The use of newer techniques for breast radiotherapy was motivated by the desire to improve dose distributions and to reduce treatmentrelated morbidity [3]. This includes three-dimensional conformal radiotherapy–with the possibility of better protecting the heart and ipsilateral lung–intensity-modulated radiotherapy, which has improved dose homogeneity and been shown to reduce acute side effects of irradiation, and helical tomotherapy, which has been shown to improve dosimetry of locoregional radiotherapy [4,5]. Other delivery techniques, such as brachytherapy, have been studied with the aim of reducing toxicity [6]. Finally, alternate patient positioning has also been explored as a means to improve dose homogeneity and to decrease exposure of organs at risk: treatment in the prone or in the lateral decubitus positions (isocentric lateral decubitus) [7–11]. We have previously shown that isocentric lateral decubitus, which has been used for many years in our institution, provides adequate local control and is associated with a no heart and lung complications [10–12]. The isocentric lateral decubitus needs dedicated immobilization devices. So far these treatments ® were performed on a Clinac (Varian Medical Systems, Palo Alto, ® CA, USA) using a Varian Exact couch designed with a removable couch top insert placed on a rail structure. However, latest Varian ® linear accelerators are equipped with an Exact IGRT couch made of advanced carbon fibre with no removable tabletop. In that case, the isocentric lateral decubitus patient positioning device has to be placed over the carbon fibre couch. The purpose of this study was to evaluate the influence of the carbon fibre couch on tolerance, acute skin toxicity and cosmetic results and facilitate the use of our technique in other hospitals. 2. Methods and materials Consecutive patients with breast cancer treated at the Curie institute with whole breast radiation in lateral position for early stage breast cancer were selected for this study. A CT scan was performed after surgery for treatment planning. Patients were placed in the lateral decubitus position on a breast board. The lateral decubitus immobilization device consists of a dedicated patient board
(Techset) with a back rest. A large elastic fabric band serves to move the contralateral breast out of the radiation fields. The patient lies on the side of her treated breast. A thin carbon breast rest of 6 or 7 cm height with angled sides is placed under the breast with its long edge along the lateral border of the breast (Fig. 1). These hollow supports have been manufactured using resistant but light carbon fibre sheets (Fig. 2). The surface of the support consists of a flat part where the breast is placed and a curved part adapted to the convexity of the thorax. The thickness of horizontal part is only 0.3 mm, allowing a good preservation of the skin by limiting the bolus effect. Images were acquired on a large bore CT scanner (AquilionTM LB, Toshiba Medical, Puteaux, France) from the mid-neck to the mid-abdomen, using 3-mm slices. Using virtual simulation (SIMAgoTM , Dosisoft, Cachan, France), two isocentric beams, medial and lateral, with matching posterior borders were set-up. The CT data and the radiotherapy plan were transferred to a commercial treatment planning system (TPS) ® (version 8.6, Varian Medical System , Palo Alto, USA) for plan optimization using AAA TM algorithm. The breast, tumour bed and organs at risk were delineated: heart was contoured from the level of the pulmonary trunk to the apex to include the pericardium. Both lungs and were delineated. All patients were planned for treatment with whole breast irradiation consisting of 50 Gy in 25 fractions in most of case, with or without tumour bed boost of 16 Gy in eight fractions. Other scheme that administered a total dose of 41.6 Gy in 13 fractions (three weekly fractions), or 40.05 Gy in 15 fractions (five weekly fractions) have been used in patients older than 60 years, for node negative tumours that did not need a boost (small, low grade lesions). Depending on performance status and age of the patients, a « flash » treatment administrating a total dose of 30 Gy in five fractions or 28,5 Gy in five fractions (one weekly fraction) can be used (especially in elderly patients) [13]. These treatments were performed on linear accelerators 1 and 2 ® using a Varian Exact couch designed with a removable couch top insert placed on a rail structure. The isocentric lateral decubitus positioning device was directly placed on the rail structure instead of the removable couch top. Linear accelerator 3 is equipped with ® an Exact IGRT carbon fibre couch with no removable tabletop. In that case, the isocentric lateral decubitus positioning device has to be placed over the carbon fibre couch. Linear accelerator 2 used 4- and 10 MV photons and linear accelerators 1 and 3 used 6 MV
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Fig. 1. Equipment for whole breast radiotherapy in the isocentric lateral decubitus position. a: patient position; b: immobilization devices: table, disposal under the breast (carbon fibre) for the patients’ everyday positioning, the disposal to fix the elastic band to keep the contralateral breast out of irradiated volumes.
photons. Tumour bed boost was performed in the isocentric lateral decubitus position, using 4 or 6 MV photons. Digitally reconstructed radiographs are produced and registered weekly, during treatment, to the portal images. All patients were evaluated weekly by the radiation oncologist, and acute toxicity was assessed using the National Cancer Institute (NCI) Common Toxicity Criteria (CTC) v 3.0 scale. Late toxicity and cosmetic results were evaluated 18 months after the radiation therapy. Cosmetic results were defined as excellent, good, middle or bad. Interruption of radiation therapy based on acute toxicity was reported.
2.1. Physics Difference between the three linear accelerators was based on energy and the fact that latest Varian linear accelerators are ® equipped with an Exact IGRT couch made of advanced carbon fibre with no removable tabletop. In that case, the isocentric lateral decubitus patient positioning device has to be placed over the carbon fibre couch. To evaluate the influence of the carbon fibre couch on the dose received by the external area of the breast in lateral decubitus position, we performed percentage depth dose measurements using a NACP-02 parallel-plate chamber (IBA Dosimetry GmbH, Schwarzenbruck, Germany). Measurements were made with Solid
®
Water HE slab phantoms (Gammex, Middleton, WI, USA) using 4, 6 and 10 MV photon beams. The first set of measurements was done by inserting the isocentric lateral decubitus patient positioning device (couch top + carbon epoxy disposer) between the beam and the parallel-plate chamber. The second set of measurements was done by adding the carbon fibre couch. Skin doses were compared for all energies and both setups. 2.2. Statistics A chi-squared test and Student’s t test were used to compare skin toxicity and cosmetic results between the three linear accelerators. For all analyses, a p-value of <0.05 was considered as significant. 3. Results 3.1. Patients characteristics This retrospective study concerned 246 consecutive patients treated from January 2013 to February 2014. Patient and tumour characteristics are given in Table 1. Median follow-up for the 248 patients was 18 months. In most patients, bra and cup size were collected. As described in a previous article a breast circumference
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Fig. 2. Equipment for whole breast radiotherapy in the isocentric lateral decubitus position: Varian Exact couch designed with a removable couch top insert placed on a rail structure. The isocentric lateral decubitus positioning device is directly placed on the rail structure instead of the removable couch top.
of 95 cm and « C » cup were most common, confirming the large breast size in this population. Risk factors of acute skin toxicity were reported such smoking, diabetes, skin and/or systemic deseases. In terms of risk factors, the patients treated on linear accelerators Nos. 1-2-or 3 were comparable. 3.2. Treatment characteristics Boost radiotherapy was given in 144 patients (58%), of them 120 patients (48%) received a total dose of 50 Gy to the whole breast; 103 patients (42%) did not meet the criteria for a boost. An hypofractionned scheme was prescribed in 85 patients (34%) and 39 patients (15%) received a « flash » scheme. Treatment characteristics are presented in Table 2. 3.3. Physics We showed that the use of the carbon fibre couch increases the surface dose by more than 35% compared to the dose given by a beam that only goes through the isocentric lateral decubitus patient positioning device (Fig. 3). To minimise potential skin reactions related to the increased surface dose for linear accelerator
3 treatments, weights of anterior and posterior beams were modified as follows: 60% for the anterior beam and 40% for the posterior beam. 3.4. Clinical results 3.4.1. Acute and late toxicity 3.4.1.1. Normofractionated radiotherapy. Normofractionated radiotherapy delivered 50 Gy in 25 fractions (five weekly fractions) with or without 16 Gy in eight fractions. Acute skin toxicity of normofractionated radiotherapy in the isocentric lateral decubitus position on the three linear accelerators was acceptable: 47% of patients experienced grade 1 dermatitis, while 50% - grade 2 and 3%: grade 3. There was no difference between the three linear accelerators (P = 0.2). Two by two comparison did not show any difference, between linear accelerators 3 and 2 (P = 0.16) nor between linear accelerators 3 and 1 (P = 0.98). Late toxicity was acceptable with 84% of grade 0–1 fibrosis and 2% of grade 2–3, 14% were not notified. There was no difference between the three linear accelerators (P = 0.44). Two by two comparison did not show any difference, between linear accelerators 3 and 2 (P = 1) nor between linear accelerators 3 and 1 (P = 0.39).
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Table 1 Study on whole breast radiotherapy in the isocentric lateral decubitus position: patients and tumour characteristics (n = 248). Linear accelerators
Patient characteristics Median age [range] Smoking Diabetes Performance status 0–1 2 Lesion location Left breast Right breast Histology Invasive lobular or ductal carcinoma Ductal carcinoma in situ Stage T0–T1N0 T2N0 Bra size cup A B C D E NC Bra size 80–85 cm 90–95 cm 100–105 cm 110 cm 120 cm NC
P
No. 1
No. 2
No. 3
67 years [35–91 years] 14 (14.5%) 2 (2%)
66 years [42–86 years] 8 (9.4%) 3 (3.5%)
68 years [32–97 years] 10 (14.9%) 2 (2.9%)
86 (89.5%) 10 (10.5%)
72 (84.7%) 13 (15.3%)
65 (97%) 2 (3%)
50 (52%) 46 (48%)
39 (45.8%) 46 (54.2%)
34 (50.7%) 33 (49.3%)
81 (84.3%) 15 (15.7%)
73 (85.8%) 12 (14.2%)
58 (86.5%) 9 (13.5%)
82 (85.4%) 14 (14.6%)
73 (85.8%) 11 (12.9%)
60 (89.5%) 7 (10.5%)
0 18 (18.75%) 31 (32.3%) 23 (23.9%) 2 (2%) 14 (14.6%)
1 (1.2%) 22 (25.8%) 19 (22.3%) 16 (18.8%) 5 (5.9%) 19 (22.3%)
2 (3%) 14 (20.9%) 23 (34.3%) 8 (11.9%) 3 (4.5%) 17 (25.3%)
2 (2%) 52 (54.2%) 15 (15.6%) 6 (6.2%) 1 (1%) 18 (18.7%)
8 (9.4%) 43 (50.6%) 9 (10.6%) 3 (3.5%) 0 21 (24.7%)
9 (13.4%) 28 (41.8%) 13 (19.4%) 3 (4.4%) 1 (1.5%) 12 (17.9%)
0.04
0.72
0.9
0.74
Table 2 Study on whole breast radiotherapy in the isocentric lateral decubitus position: treatment characteristics in relationship with the machines (n = 248). Characteristics
Normofractionated radiotherapy Hypofractionned radiotherapy Flash scheme Boost No boost Treatment energy
Adjuvant chemotherapy Concomitant systemic treatments
Linear accelerators No. 1
No. 2
No. 3
44 (45,8%) 35 (36,4%) 14 (14,9%) 56 (58.3%) 40 (41.6%) 6 MV
44 (51,7%) 25 (29.4%) 15 (17.6%) 47 (56%) 37 (44%)
32 (47.8%) 25 (37.3%) 10 (14.9%) 41 (61.1%) 26 (38.8%) 6 MV
9 (9.3%) 0
3.4.1.2. Hypofractionated radiotherapy. Hypofractionated radiotherapy was realized mostly to a total dose of 41.6 Gy in 13 fractions in 5 weeks, or 40.05 Gy in 15 fractions in 3 weeks. Acute skin toxicity of hypofractionated radiotherapy in the isocentric lateral decubitus position on the three linear accelerators was excellent, with a majority of grade 0–1 dermatitis in 89% of patients, while 11% experienced grade 2 dermatitis. There was no difference in terms of toxicity between the 3 linear accelerators (P = 0.9) or two by two comparisons between linear accelerators 3 and 2 (P = 1) and between linear accelerators 3 and 1 (P = 1). Concerning late toxicity, 94% of patients experienced grade 0–1 fibrosis, there was no grade 2–4 fibrosis and 6% were not notified without any difference between 3 linear accelerators (P = 1). 3.4.1.3. “Flash” treatment. The “flash” treatment delivered 30 Gy in five fractions in 5 weeks or 28,5 Gy in five fractions in 5 weeks. The acute skin tolerance was excellent with a majority of grade 0–1 dermatitis: 90% of patients while 10% experienced grade
4 MV (92%) 4–10 MV (8%) 19 (22.35%) 1 (1.18%)
7 (10.4%) 6 (7%)
2 dermatitis. There was no difference between the three linear accelerators (P = 0.2) and two by two comparisons between linear accelerators 3 and 2 (P = 1) nor between linear accelerators 3 and 1 (P = 0.16). Late toxicity was as following: 77% of grade 0–1 fibrosis, 2.6% of grade 2–3 fibrosis and 20% were not notified. There was no difference between the three machines (P = 0.22). 3.4.2. Cosmetic outcomes The cosmetic outcome of treatment was assessed using a 4-point scale in 214 of the 248 patients: 21% of patients had an excellent cosmetic outcome, most of patients (60%) had a good cosmetic outcome, 5% of patients had a middle cosmetic outcome and only 0.4% of patients had a fair outcome. 3.4.3. Treatment interruptions Treatment was interrupted for seven patients (7.3%) on linear accelerator 1, three patients (3.5%) on linear accelerator 2, and six patients (8.9%) on linear accelerator 3, for grade 2–3 dermatitis in all cases.
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Fig. 3. Study on whole breast radiotherapy in the isocentric lateral decubitus position: variation of the depth dose as a function of the energy and the Exact IGRT carbon fibre couch (n = 248). Blue: 4 MV photons; turquoise blue: 6 MV photons; green 10 MV photons; Pink: 6 MV with a carbon fibre couch without removable tabletop.
4. Discussion This was the first study on the changes realized in new modern machines with their tables and the clinical tolerance using our previously described technique in lateral position. We had no clinical difference in terms of toxicity between three different linear accelerators with different tables. Our results show that with the evolution of tables of the new accelerators we can continue to use safely the described technique, obviously after physics and dosimetric verifications. In a recent study, we have also shown an excellent local control with only 4.3% of local and or regional recurrences in 6.4 years [14]. Our results show acceptable acute and late skin toxicity with a very low rate of grade 3 dermatitis. Our results are in accord with those reported by Stegsman et al. with prone position, where grade 3 acute dermatitis was limited to 2% of patients and chronic grade 2–3 skin and subcutaneous tissue toxicity was reported in 4.4% and 13.7% of patients, respectively [15]. The rate of grade 3 dermatitis and grade 2–3 fibrosis in our study was very low, despite patients having larger breast sizes than in the previously published study which reported 27–36% of grade 3–4 dermatitis depending on whether intensity-modulated irradiation was used [16]. Nevertheless, our results confirms that the anatomic advantages of the lateral decubitus position may be particularly useful in hypofractionated whole breast irradiation. We did not report grade 2–3 fibrosis in hypofractioned radiotherapy and only 2.6% grade 2–3 fibrosis in « flash » treatment. About the physics measurements, further in vivo measurements with thermoluminescent devices would be necessary to confirm water-equivalent slab phantoms measurements. It would also allow improving the weight of the anterior and posterior beams especially according to the thickness of the breast. Indeed, implementing this method for rather thin breast (less than 5 cm) could lead to an increase of skin reactions due to the dose contribution of the anterior beam to the external area of the breast. 5. Conclusion We showed that the whole breast irradiation delivered in the lateral decubitus position is reproducible, well tolerated and the clinical results are comparable regardless of the different modalities allowed by different linear accelerators and the table structure,
as well as the dosimetric differences. Further prospective studies and an additional follow-up are needed to confirm our results. Funding No grants support. Disclosure of interest The authors declare that they have no competing interest. References [1] Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Darby S, McGale P, Correa C, Taylor C, Arriagada R, et al. Effect of radiotherapy after breastconserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 2011;378:1707–16. [2] Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233–41. [3] Henson KE, McGale P, Taylor C, Darby SC. Radiation-related mortality from heart disease and lung cancer more than 20 years after radiotherapy for breast cancer. Br J Cancer 2013;108:179–82. [4] Pignol JP, Olivotto I, Rakovitch E, Gardner S, Sixel K, Beckham W, et al. A multicenter randomized trial of breast intensity- modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol 2008;26:2085–92. [5] Goddu SM, Chaudhari S, Mamalui-Hunter M, Pechenaya OL, Pratt D, Mutic S, et al. Helical tomotherapy planning for left-sided breast cancer patients with positive lymph nodes: comparison to conventional multiport breast technique. Int J Radiat Oncol Biol Phys 2009;73:1243–51. [6] Strnad V, Hildebrandt G, Pötter R, Hammer J, Hindemith M, Resch A, et al. Accelerated partial breast irradiation: 5-year results of the German-Austrian multicenter phase II trial using interstitial multicatheter brachytherapy alone after breast- conserving surgery. Int J Radiat Oncol Biol Phys 2011;80:17–24. [7] Lymberis SC, de Wyngaert JK, Parhar P, Chhabra AM, Fenton-Kerimian M, Chang J, et al. Prospective assessment of optimal individual position (prone versus supine) for breast radiotherapy: volumetric and dosimetric correlations in 100 patients. J Radiat Oncol Biol Phys 2012;84:902–9. [8] Fourquet A, Campana F, Rosenwald JC, Vilcoq JR. Breast irradiation in the lateral decubitus position: technique of the institut Curie. Radiother Oncol 1991;22:261–5. [9] Campana F, Kirova YM, Rosenwald JC, Dendale R, Vilcoq JR, Dreyfus H, et al. Breast radiotherapy in the lateral decubitus position: A technique to prevent lung and heart irradiation. Int J Radiat Oncol Biol Phys 2005;61:1348–54. [10] Kirova YM, Campana F, Savignoni A, Laki F, Muresan M, Dendale R, et al. Breast-conserving treatment in the elderly: long-term results of adjuvant hypofractionated and normofractionated radiotherapy. Int J Radiat Oncol Biol Phys 2009;75:76–81.
S. Krhili et al. / Cancer/Radiothérapie 23 (2019) 209–215 [11] Ludwig MS, McNeese MD, Buchholz TA, Perkins GH, Strom EA. The lateral decubitus breast boost: description, rationale, and efficacy. Int J Radiat Oncol Biol Phys 2010;76:100–3. [12] Kirova YM, Hijal T, Campana F, Fournier-Bidoz N, Stilhart A, Dendale R, et al. Whole breast radiotherapy in the lateral decubitus position: a dosimetric and clinical solution to decrease the doses to the organs at risk (OAR). Radiother Oncol 2014;110:477–81. [13] Chargari C, Kirova YM, Laki F, Savignoni A, Dorval T, Dendale R, et al. The impact of the loco-regional treatment in elderly breast cancer patients: hypofractionated exclusive radiotherapy, single institution long-term results. Breast 2010;19:413–6.
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[14] Bronsart E, Dureau S, Xu HP, Bazire L, Chilles A, Costa E, et al. Whole breast radiotherapy in the lateral isocentric lateral decubitus position: Long-term efficacy and toxicity results. Radiother Oncol 2017;124:214–9. [15] Stegman LD, Beal KP, Hunt MA, Fornier MN, McCormick B. Long- term clinical outcomes of whole-breast irradiation delivered in the prone position. Int J Radiat Oncol Biol Phys 2007;68:73–81. [16] Pignol JP, Olivotto I, Rakovitch E, Gardner S, Sixel K, Beckham W, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol 2008;26:2085–92.
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Original article
Whole breast radiotherapy in the isocentric lateral decubitus position: Role of the immobilization device and table on clinical results Irradiation du sein en position latérale isocentrique : rôle de la table et des dispositifs d’immobilisation S. Krhili a , E. Costa a , H.-P. Xu a,b , Y.M. Kirova a,∗ a b
Department of Radiation Oncology, institut Curie, 26, rue d’Ulm, 75005 Paris, France Department of Radiation Oncology, Ruijin Hospital, Shangai Jiaotong University, School of Medicine, Shanghai, China
a r t i c l e
i n f o
Article history: Received 13 July 2018 Received in revised form 20 September 2018 Accepted 27 September 2018 Keywords: Breast cancer Isocentric lateral decubitus Immobilization device
a b s t r a c t Purpose. – To evaluate clinical results and the “effect bolus” based on the table design of different linear accelerators in patients with breast cancer treated by previously published whole breast irradiation in the isocentric lateral decubitus position. Material and methods. – We studied 248 consecutive female patients with early stage breast cancer treated by conservative surgery followed by three-dimensional conformal whole breast irradiation in the isocentric lateral decubitus position between January 2013 and February 2014. Radiotherapy was performed on linear accelerators using a Varian. The energy used was 4 and 10 MV photons or 6 MV photons. All patients were evaluated weekly by the radiation oncologist, acute toxicity was assessed using the NCICTC v 3.0 scale. Late toxicity and cosmetic results were evaluated 18 months after the radiotherapy. Cosmetic results were defined as excellent, good, middle or bad. Results. – Among the 248 women included, the median age was 67 years (range: 35–91 years). All received whole breast radiotherapy with boost in 144 patients (58%). One-hundred-twenty patients received normofractionated and 124 patients hypofractionated whole breast radiotherapy. Median follow-up was 18 months. Acute skin toxicity in the whole breast radiotherapy in the isocentric lateral decubitus position was acceptable: there was 47% of grade 1 radiodermatitis, 50% of grade 2 and 3% grade 3 and no grade 4 for normofractionated radiotherapy; 89% of grade 1 dermatitis and 11% of grade 2 for hypofractionated radiotherapy; 89.7% of grade 0–1 dermatitis and 10.3% of grade 2 for the “flash” scheme and did not differ between the three linear accelerators (P = 0.2, P = 0.9 and P = 0.2 respectively for the normofractionated radiotherapy, hypofractionated radiotherapy and the “flash”scheme). Late toxicity was acceptable with 84% of grade 0–1 fibrosis for normofractionated radiotherapy, 94% of patients for hypofractionated radiotherapy and 77% for “flash” scheme and did not differ between the three linear accelerators (P = 0.44, P = 1 and P = 0.22 resp.). Most of patients (81%) had an excellent or a good cosmetic outcome. Conclusions. – Whole breast radiotherapy in the isocentric lateral decubitus position is well tolerated. Clinical results are comparable based on different immobilization device allowed by linear accelerators. Particularly, there was no influence of the couch on skin tolerance and cosmetic results. ´ e´ franc¸aise de radiotherapie ´ oncologique (SFRO). Published by Elsevier Masson SAS. All © 2019 Societ rights reserved.
r é s u m é Mots clés : Cancer du sein Position latérale isocentrique Dispositifs d’immobilisation
Objectif de l’étude. – L’objectif était d’évaluer les résultats cliniques et un « effet bolus » possible de la table de différents accélérateurs linaires dans le cadre de la prise en charge avec la technique de décubitus latéral isocentrique de patientes atteintes d’un cancer du sein. Matériel et méthodes. – Nous avons étudié rétrospectivement les dossiers de 248 patientes atteintes d’un cancer du sein traité précocement avec une chirurgie conservatrice suivie par une irradiation en décubitus latéral isocentrique entre janvier 2013 et février 2014. La radiothérapie a été réalisée par accélérateurs
∗ Corresponding author. E-mail address: [email protected] (Y.M. Kirova). https://doi.org/10.1016/j.canrad.2018.09.001 ´ e´ franc¸aise de radiotherapie ´ 1278-3218/© 2019 Societ oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.
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Varian avec des énergies de photons de 4 et 10 MV et 6 MV. La toxicité aigüe a été évaluée selon les National Cancer Institute Common Toxicity Criteria (NCICTC) v 3.0. Une évaluation des résultats esthétiques (définis comme excellents, bons, moyens et mauvais) et de la toxicité tardive ont a été faite 18 mois après la fin de la radiothérapie. Résultats. – L’âge médian était de 67 ans (de 35 à 91 ans). Toutes les patients ont rec¸u une irradiation mammaire en décubitus latéral isocentrique et dans 144 cas (58 %) avec un complément au niveau du lit opératoire. Cent-vingt patientes ont rec¸u une irradiation normofractionnée et 124 hypofractionnée. Le suivi médian était de 18 mois. La toxicité précoce cutanée était acceptable, avec 47 % de cas de grade 1, 50 % de grade 2 et 3 % de grade et 0 % de grade 4 avec l’irradiation normofractionnée, 89 % de grade 1 et 11 % de grade 2 avec l’irradiation hypofractionnée, 89,7 % de grade 0–1 et 10,3 % de grade 2 avec l’irradiation en flash, sans différence entre les trois accélérateurs linéaires (respectivement p = 0,2, p = 0,9 et p = 0,2). La toxicité tardive était acceptable avec 84 % de fibroses de grade 0–1 pour la radiothérapie normofractionnée, 94 % pour celle hypofractionnée et 77 % pour le schéma “flash”, sans différence entre les trois accélérateurs linéaires (respectivement p = 0,44, p = 1 and p = 0,22). Pour une grande partie des patientes (81 %), le résultat esthétique était excellent ou bon. Conclusions. – La radiothérapie était bien tolérée et les résultats cliniques étaient comparables malgré les différences du matériel sur les différentes machines en termes de résultats esthétiques et tolérance cutanée. ´ e´ franc¸aise de radiotherapie ´ © 2019 Societ oncologique (SFRO). Publie´ par Elsevier Masson SAS. Tous ´ ´ droits reserv es.
1. Introduction After breast-conserving surgery for early breast cancer, breast irradiation decreases the rate of local recurrence significantly [1,2]. Standard breast radiation technique is tangential radiation delivered to the breast in the dorsal supine position. The use of newer techniques for breast radiotherapy was motivated by the desire to improve dose distributions and to reduce treatmentrelated morbidity [3]. This includes three-dimensional conformal radiotherapy–with the possibility of better protecting the heart and ipsilateral lung–intensity-modulated radiotherapy, which has improved dose homogeneity and been shown to reduce acute side effects of irradiation, and helical tomotherapy, which has been shown to improve dosimetry of locoregional radiotherapy [4,5]. Other delivery techniques, such as brachytherapy, have been studied with the aim of reducing toxicity [6]. Finally, alternate patient positioning has also been explored as a means to improve dose homogeneity and to decrease exposure of organs at risk: treatment in the prone or in the lateral decubitus positions (isocentric lateral decubitus) [7–11]. We have previously shown that isocentric lateral decubitus, which has been used for many years in our institution, provides adequate local control and is associated with a no heart and lung complications [10–12]. The isocentric lateral decubitus needs dedicated immobilization devices. So far these treatments ® were performed on a Clinac (Varian Medical Systems, Palo Alto, ® CA, USA) using a Varian Exact couch designed with a removable couch top insert placed on a rail structure. However, latest Varian ® linear accelerators are equipped with an Exact IGRT couch made of advanced carbon fibre with no removable tabletop. In that case, the isocentric lateral decubitus patient positioning device has to be placed over the carbon fibre couch. The purpose of this study was to evaluate the influence of the carbon fibre couch on tolerance, acute skin toxicity and cosmetic results and facilitate the use of our technique in other hospitals. 2. Methods and materials Consecutive patients with breast cancer treated at the Curie institute with whole breast radiation in lateral position for early stage breast cancer were selected for this study. A CT scan was performed after surgery for treatment planning. Patients were placed in the lateral decubitus position on a breast board. The lateral decubitus immobilization device consists of a dedicated patient board
(Techset) with a back rest. A large elastic fabric band serves to move the contralateral breast out of the radiation fields. The patient lies on the side of her treated breast. A thin carbon breast rest of 6 or 7 cm height with angled sides is placed under the breast with its long edge along the lateral border of the breast (Fig. 1). These hollow supports have been manufactured using resistant but light carbon fibre sheets (Fig. 2). The surface of the support consists of a flat part where the breast is placed and a curved part adapted to the convexity of the thorax. The thickness of horizontal part is only 0.3 mm, allowing a good preservation of the skin by limiting the bolus effect. Images were acquired on a large bore CT scanner (AquilionTM LB, Toshiba Medical, Puteaux, France) from the mid-neck to the mid-abdomen, using 3-mm slices. Using virtual simulation (SIMAgoTM , Dosisoft, Cachan, France), two isocentric beams, medial and lateral, with matching posterior borders were set-up. The CT data and the radiotherapy plan were transferred to a commercial treatment planning system (TPS) ® (version 8.6, Varian Medical System , Palo Alto, USA) for plan optimization using AAA TM algorithm. The breast, tumour bed and organs at risk were delineated: heart was contoured from the level of the pulmonary trunk to the apex to include the pericardium. Both lungs and were delineated. All patients were planned for treatment with whole breast irradiation consisting of 50 Gy in 25 fractions in most of case, with or without tumour bed boost of 16 Gy in eight fractions. Other scheme that administered a total dose of 41.6 Gy in 13 fractions (three weekly fractions), or 40.05 Gy in 15 fractions (five weekly fractions) have been used in patients older than 60 years, for node negative tumours that did not need a boost (small, low grade lesions). Depending on performance status and age of the patients, a « flash » treatment administrating a total dose of 30 Gy in five fractions or 28,5 Gy in five fractions (one weekly fraction) can be used (especially in elderly patients) [13]. These treatments were performed on linear accelerators 1 and 2 ® using a Varian Exact couch designed with a removable couch top insert placed on a rail structure. The isocentric lateral decubitus positioning device was directly placed on the rail structure instead of the removable couch top. Linear accelerator 3 is equipped with ® an Exact IGRT carbon fibre couch with no removable tabletop. In that case, the isocentric lateral decubitus positioning device has to be placed over the carbon fibre couch. Linear accelerator 2 used 4- and 10 MV photons and linear accelerators 1 and 3 used 6 MV
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Fig. 1. Equipment for whole breast radiotherapy in the isocentric lateral decubitus position. a: patient position; b: immobilization devices: table, disposal under the breast (carbon fibre) for the patients’ everyday positioning, the disposal to fix the elastic band to keep the contralateral breast out of irradiated volumes.
photons. Tumour bed boost was performed in the isocentric lateral decubitus position, using 4 or 6 MV photons. Digitally reconstructed radiographs are produced and registered weekly, during treatment, to the portal images. All patients were evaluated weekly by the radiation oncologist, and acute toxicity was assessed using the National Cancer Institute (NCI) Common Toxicity Criteria (CTC) v 3.0 scale. Late toxicity and cosmetic results were evaluated 18 months after the radiation therapy. Cosmetic results were defined as excellent, good, middle or bad. Interruption of radiation therapy based on acute toxicity was reported.
2.1. Physics Difference between the three linear accelerators was based on energy and the fact that latest Varian linear accelerators are ® equipped with an Exact IGRT couch made of advanced carbon fibre with no removable tabletop. In that case, the isocentric lateral decubitus patient positioning device has to be placed over the carbon fibre couch. To evaluate the influence of the carbon fibre couch on the dose received by the external area of the breast in lateral decubitus position, we performed percentage depth dose measurements using a NACP-02 parallel-plate chamber (IBA Dosimetry GmbH, Schwarzenbruck, Germany). Measurements were made with Solid
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Water HE slab phantoms (Gammex, Middleton, WI, USA) using 4, 6 and 10 MV photon beams. The first set of measurements was done by inserting the isocentric lateral decubitus patient positioning device (couch top + carbon epoxy disposer) between the beam and the parallel-plate chamber. The second set of measurements was done by adding the carbon fibre couch. Skin doses were compared for all energies and both setups. 2.2. Statistics A chi-squared test and Student’s t test were used to compare skin toxicity and cosmetic results between the three linear accelerators. For all analyses, a p-value of <0.05 was considered as significant. 3. Results 3.1. Patients characteristics This retrospective study concerned 246 consecutive patients treated from January 2013 to February 2014. Patient and tumour characteristics are given in Table 1. Median follow-up for the 248 patients was 18 months. In most patients, bra and cup size were collected. As described in a previous article a breast circumference
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Fig. 2. Equipment for whole breast radiotherapy in the isocentric lateral decubitus position: Varian Exact couch designed with a removable couch top insert placed on a rail structure. The isocentric lateral decubitus positioning device is directly placed on the rail structure instead of the removable couch top.
of 95 cm and « C » cup were most common, confirming the large breast size in this population. Risk factors of acute skin toxicity were reported such smoking, diabetes, skin and/or systemic deseases. In terms of risk factors, the patients treated on linear accelerators Nos. 1-2-or 3 were comparable. 3.2. Treatment characteristics Boost radiotherapy was given in 144 patients (58%), of them 120 patients (48%) received a total dose of 50 Gy to the whole breast; 103 patients (42%) did not meet the criteria for a boost. An hypofractionned scheme was prescribed in 85 patients (34%) and 39 patients (15%) received a « flash » scheme. Treatment characteristics are presented in Table 2. 3.3. Physics We showed that the use of the carbon fibre couch increases the surface dose by more than 35% compared to the dose given by a beam that only goes through the isocentric lateral decubitus patient positioning device (Fig. 3). To minimise potential skin reactions related to the increased surface dose for linear accelerator
3 treatments, weights of anterior and posterior beams were modified as follows: 60% for the anterior beam and 40% for the posterior beam. 3.4. Clinical results 3.4.1. Acute and late toxicity 3.4.1.1. Normofractionated radiotherapy. Normofractionated radiotherapy delivered 50 Gy in 25 fractions (five weekly fractions) with or without 16 Gy in eight fractions. Acute skin toxicity of normofractionated radiotherapy in the isocentric lateral decubitus position on the three linear accelerators was acceptable: 47% of patients experienced grade 1 dermatitis, while 50% - grade 2 and 3%: grade 3. There was no difference between the three linear accelerators (P = 0.2). Two by two comparison did not show any difference, between linear accelerators 3 and 2 (P = 0.16) nor between linear accelerators 3 and 1 (P = 0.98). Late toxicity was acceptable with 84% of grade 0–1 fibrosis and 2% of grade 2–3, 14% were not notified. There was no difference between the three linear accelerators (P = 0.44). Two by two comparison did not show any difference, between linear accelerators 3 and 2 (P = 1) nor between linear accelerators 3 and 1 (P = 0.39).
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Table 1 Study on whole breast radiotherapy in the isocentric lateral decubitus position: patients and tumour characteristics (n = 248). Linear accelerators
Patient characteristics Median age [range] Smoking Diabetes Performance status 0–1 2 Lesion location Left breast Right breast Histology Invasive lobular or ductal carcinoma Ductal carcinoma in situ Stage T0–T1N0 T2N0 Bra size cup A B C D E NC Bra size 80–85 cm 90–95 cm 100–105 cm 110 cm 120 cm NC
P
No. 1
No. 2
No. 3
67 years [35–91 years] 14 (14.5%) 2 (2%)
66 years [42–86 years] 8 (9.4%) 3 (3.5%)
68 years [32–97 years] 10 (14.9%) 2 (2.9%)
86 (89.5%) 10 (10.5%)
72 (84.7%) 13 (15.3%)
65 (97%) 2 (3%)
50 (52%) 46 (48%)
39 (45.8%) 46 (54.2%)
34 (50.7%) 33 (49.3%)
81 (84.3%) 15 (15.7%)
73 (85.8%) 12 (14.2%)
58 (86.5%) 9 (13.5%)
82 (85.4%) 14 (14.6%)
73 (85.8%) 11 (12.9%)
60 (89.5%) 7 (10.5%)
0 18 (18.75%) 31 (32.3%) 23 (23.9%) 2 (2%) 14 (14.6%)
1 (1.2%) 22 (25.8%) 19 (22.3%) 16 (18.8%) 5 (5.9%) 19 (22.3%)
2 (3%) 14 (20.9%) 23 (34.3%) 8 (11.9%) 3 (4.5%) 17 (25.3%)
2 (2%) 52 (54.2%) 15 (15.6%) 6 (6.2%) 1 (1%) 18 (18.7%)
8 (9.4%) 43 (50.6%) 9 (10.6%) 3 (3.5%) 0 21 (24.7%)
9 (13.4%) 28 (41.8%) 13 (19.4%) 3 (4.4%) 1 (1.5%) 12 (17.9%)
0.04
0.72
0.9
0.74
Table 2 Study on whole breast radiotherapy in the isocentric lateral decubitus position: treatment characteristics in relationship with the machines (n = 248). Characteristics
Normofractionated radiotherapy Hypofractionned radiotherapy Flash scheme Boost No boost Treatment energy
Adjuvant chemotherapy Concomitant systemic treatments
Linear accelerators No. 1
No. 2
No. 3
44 (45,8%) 35 (36,4%) 14 (14,9%) 56 (58.3%) 40 (41.6%) 6 MV
44 (51,7%) 25 (29.4%) 15 (17.6%) 47 (56%) 37 (44%)
32 (47.8%) 25 (37.3%) 10 (14.9%) 41 (61.1%) 26 (38.8%) 6 MV
9 (9.3%) 0
3.4.1.2. Hypofractionated radiotherapy. Hypofractionated radiotherapy was realized mostly to a total dose of 41.6 Gy in 13 fractions in 5 weeks, or 40.05 Gy in 15 fractions in 3 weeks. Acute skin toxicity of hypofractionated radiotherapy in the isocentric lateral decubitus position on the three linear accelerators was excellent, with a majority of grade 0–1 dermatitis in 89% of patients, while 11% experienced grade 2 dermatitis. There was no difference in terms of toxicity between the 3 linear accelerators (P = 0.9) or two by two comparisons between linear accelerators 3 and 2 (P = 1) and between linear accelerators 3 and 1 (P = 1). Concerning late toxicity, 94% of patients experienced grade 0–1 fibrosis, there was no grade 2–4 fibrosis and 6% were not notified without any difference between 3 linear accelerators (P = 1). 3.4.1.3. “Flash” treatment. The “flash” treatment delivered 30 Gy in five fractions in 5 weeks or 28,5 Gy in five fractions in 5 weeks. The acute skin tolerance was excellent with a majority of grade 0–1 dermatitis: 90% of patients while 10% experienced grade
4 MV (92%) 4–10 MV (8%) 19 (22.35%) 1 (1.18%)
7 (10.4%) 6 (7%)
2 dermatitis. There was no difference between the three linear accelerators (P = 0.2) and two by two comparisons between linear accelerators 3 and 2 (P = 1) nor between linear accelerators 3 and 1 (P = 0.16). Late toxicity was as following: 77% of grade 0–1 fibrosis, 2.6% of grade 2–3 fibrosis and 20% were not notified. There was no difference between the three machines (P = 0.22). 3.4.2. Cosmetic outcomes The cosmetic outcome of treatment was assessed using a 4-point scale in 214 of the 248 patients: 21% of patients had an excellent cosmetic outcome, most of patients (60%) had a good cosmetic outcome, 5% of patients had a middle cosmetic outcome and only 0.4% of patients had a fair outcome. 3.4.3. Treatment interruptions Treatment was interrupted for seven patients (7.3%) on linear accelerator 1, three patients (3.5%) on linear accelerator 2, and six patients (8.9%) on linear accelerator 3, for grade 2–3 dermatitis in all cases.
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Fig. 3. Study on whole breast radiotherapy in the isocentric lateral decubitus position: variation of the depth dose as a function of the energy and the Exact IGRT carbon fibre couch (n = 248). Blue: 4 MV photons; turquoise blue: 6 MV photons; green 10 MV photons; Pink: 6 MV with a carbon fibre couch without removable tabletop.
4. Discussion This was the first study on the changes realized in new modern machines with their tables and the clinical tolerance using our previously described technique in lateral position. We had no clinical difference in terms of toxicity between three different linear accelerators with different tables. Our results show that with the evolution of tables of the new accelerators we can continue to use safely the described technique, obviously after physics and dosimetric verifications. In a recent study, we have also shown an excellent local control with only 4.3% of local and or regional recurrences in 6.4 years [14]. Our results show acceptable acute and late skin toxicity with a very low rate of grade 3 dermatitis. Our results are in accord with those reported by Stegsman et al. with prone position, where grade 3 acute dermatitis was limited to 2% of patients and chronic grade 2–3 skin and subcutaneous tissue toxicity was reported in 4.4% and 13.7% of patients, respectively [15]. The rate of grade 3 dermatitis and grade 2–3 fibrosis in our study was very low, despite patients having larger breast sizes than in the previously published study which reported 27–36% of grade 3–4 dermatitis depending on whether intensity-modulated irradiation was used [16]. Nevertheless, our results confirms that the anatomic advantages of the lateral decubitus position may be particularly useful in hypofractionated whole breast irradiation. We did not report grade 2–3 fibrosis in hypofractioned radiotherapy and only 2.6% grade 2–3 fibrosis in « flash » treatment. About the physics measurements, further in vivo measurements with thermoluminescent devices would be necessary to confirm water-equivalent slab phantoms measurements. It would also allow improving the weight of the anterior and posterior beams especially according to the thickness of the breast. Indeed, implementing this method for rather thin breast (less than 5 cm) could lead to an increase of skin reactions due to the dose contribution of the anterior beam to the external area of the breast. 5. Conclusion We showed that the whole breast irradiation delivered in the lateral decubitus position is reproducible, well tolerated and the clinical results are comparable regardless of the different modalities allowed by different linear accelerators and the table structure,
as well as the dosimetric differences. Further prospective studies and an additional follow-up are needed to confirm our results. Funding No grants support. Disclosure of interest The authors declare that they have no competing interest. References [1] Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Darby S, McGale P, Correa C, Taylor C, Arriagada R, et al. Effect of radiotherapy after breastconserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 2011;378:1707–16. [2] Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233–41. [3] Henson KE, McGale P, Taylor C, Darby SC. Radiation-related mortality from heart disease and lung cancer more than 20 years after radiotherapy for breast cancer. Br J Cancer 2013;108:179–82. [4] Pignol JP, Olivotto I, Rakovitch E, Gardner S, Sixel K, Beckham W, et al. A multicenter randomized trial of breast intensity- modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol 2008;26:2085–92. [5] Goddu SM, Chaudhari S, Mamalui-Hunter M, Pechenaya OL, Pratt D, Mutic S, et al. Helical tomotherapy planning for left-sided breast cancer patients with positive lymph nodes: comparison to conventional multiport breast technique. Int J Radiat Oncol Biol Phys 2009;73:1243–51. [6] Strnad V, Hildebrandt G, Pötter R, Hammer J, Hindemith M, Resch A, et al. Accelerated partial breast irradiation: 5-year results of the German-Austrian multicenter phase II trial using interstitial multicatheter brachytherapy alone after breast- conserving surgery. Int J Radiat Oncol Biol Phys 2011;80:17–24. [7] Lymberis SC, de Wyngaert JK, Parhar P, Chhabra AM, Fenton-Kerimian M, Chang J, et al. Prospective assessment of optimal individual position (prone versus supine) for breast radiotherapy: volumetric and dosimetric correlations in 100 patients. J Radiat Oncol Biol Phys 2012;84:902–9. [8] Fourquet A, Campana F, Rosenwald JC, Vilcoq JR. Breast irradiation in the lateral decubitus position: technique of the institut Curie. Radiother Oncol 1991;22:261–5. [9] Campana F, Kirova YM, Rosenwald JC, Dendale R, Vilcoq JR, Dreyfus H, et al. Breast radiotherapy in the lateral decubitus position: A technique to prevent lung and heart irradiation. Int J Radiat Oncol Biol Phys 2005;61:1348–54. [10] Kirova YM, Campana F, Savignoni A, Laki F, Muresan M, Dendale R, et al. Breast-conserving treatment in the elderly: long-term results of adjuvant hypofractionated and normofractionated radiotherapy. Int J Radiat Oncol Biol Phys 2009;75:76–81.
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