Purpose
This consensus statement from the Breast Cancer Working Group of the German Society for Radiation Oncology (DEGRO) aims to define practical guidelines for accelerated partial-breast ...irradiation (APBI).
Methods
Recent recommendations for relevant aspects of APBI were summarized and a panel of experts reviewed all the relevant literature. Panel members of the DEGRO experts participated in a series of conferences, supplemented their clinical experience, performed a literature review, and formulated recommendations for implementing APBI in clinical routine, focusing on patient selection, target definition, and treatment technique.
Results
Appropriate patient selection, target definition for different APBI techniques, and basic rules for appropriate APBI techniques for clinical routine outside of clinical trials are described. Detailed recommendations for APBI in daily practice, including dose constraints, are given.
Conclusion
Guidelines are mandatory to assure optimal results of APBI using different techniques.
In November 2011, the Third European Consensus Conference on Diagnosis and Treatment of Germ-Cell Cancer (GCC) was held in Berlin, Germany. This third conference followed similar meetings in 2003 ...(Essen, Germany) and 2006 (Amsterdam, The Netherlands) Schmoll H-J, Souchon R, Krege S et al. European consensus on diagnosis and treatment of germ-cell cancer: a report of the European Germ-Cell Cancer Consensus Group (EGCCCG). Ann Oncol 2004; 15: 1377–1399; Krege S, Beyer J, Souchon R et al. European consensus conference on diagnosis and treatment of germ-cell cancer: a report of the second meeting of the European Germ-Cell Cancer Consensus group (EGCCCG): part I. Eur Urol 2008; 53: 478–496; Krege S, Beyer J, Souchon R et al. European consensus conference on diagnosis and treatment of germ-cell cancer: a report of the second meeting of the European Germ-Cell Cancer Consensus group (EGCCCG): part II. Eur Urol 2008; 53: 497–513. A panel of 56 of 60 invited GCC experts from all across Europe discussed all aspects on diagnosis and treatment of GCC, with a particular focus on acute and late toxic effects as well as on survivorship issues.
The panel consisted of oncologists, urologic surgeons, radiooncologists, pathologists and basic scientists, who are all actively involved in care of GCC patients. Panelists were chosen based on the publication activity in recent years. Before the meeting, panelists were asked to review the literature published since 2006 in 20 major areas concerning all aspects of diagnosis, treatment and follow-up of GCC patients, and to prepare an updated version of the previous recommendations to be discussed at the conference. In addition, ∼50 E-vote questions were drafted and presented at the conference to address the most controversial areas for a poll of expert opinions. Here, we present the main recommendations and controversies of this meeting. The votes of the panelists are added as online supplements.
Objective
To update the practical guidelines for radiotherapy of patients with locoregional breast cancer recurrences based on the current German interdisciplinary S3 guidelines 2012.
Methods
A ...comprehensive survey of the literature using the search phrases “locoregional breast cancer recurrence”, “chest wall recurrence”, “local recurrence”, “regional recurrence”, and “breast cancer” was performed, using the limits “clinical trials”, “randomized trials”, “meta-analysis”, “systematic review”, and “guidelines”.
Conclusions
Patients with isolated in-breast or regional breast cancer recurrences should be treated with curative intent. Mastectomy is the standard of care for patients with ipsilateral breast tumor recurrence. In a subset of patients, a second breast conservation followed by partial breast irradiation (PBI) is an appropriate alternative to mastectomy. If a second breast conservation is performed, additional irradiation should be mandatory. The largest reirradiation experience base exists for multicatheter brachytherapy; however, prospective clinical trials are needed to clearly define selection criteria, long-term local control, and toxicity.
Following primary mastectomy, patients with resectable locoregional breast cancer recurrences should receive multimodality therapy including systemic therapy, surgery, and radiation +/− hyperthermia. This approach results in high local control rates and long-term survival is achieved in a subset of patients. In radiation-naive patients with unresectable locoregional recurrences, radiation therapy is mandatory. In previously irradiated patients with a high risk of a second local recurrence after surgical resection or in patients with unresectable recurrences, reirradiation should be strongly considered. Indication and dose concepts depend on the time interval to first radiotherapy, presence of late radiation effects, and concurrent or sequential systemic treatment. Combination with hyperthermia can further improve tumor control.
In patients with isolated axillary or supraclavicular recurrence, durable disease control is best achieved with multimodality therapy including surgery and radiotherapy. Radiation therapy significantly improves local control and should be applied whenever feasible.
Background and purpose
The aim of the present paper is to update the practical guidelines for postoperative adjuvant radiotherapy of breast cancer published in 2007 by the breast cancer expert panel ...of the German Society for Radiooncology (Deutsche Gesellschaft für Radioonkologie, DEGRO). The present recommendations are based on a revision of the German interdisciplinary S-3 guidelines published in July 2012.
Methods
A comprehensive survey of the literature concerning radiotherapy following breast conserving therapy (BCT) was performed using the search terms “breast cancer”, “radiotherapy”, and “breast conserving therapy”. Data from lately published meta-analyses, recent randomized trials, and guidelines of international breast cancer societies, yielding new aspects compared to 2007, provided the basis for defining recommendations according to the criteria of evidence-based medicine. In addition to the more general statements of the DKG (Deutsche Krebsgesellschaft), this paper addresses indications, target definition, dosage, and technique of radiotherapy of the breast after conservative surgery for invasive breast cancer.
Results
Among numerous reports on the effect of radiotherapy during BCT published since the last recommendations, the recent EBCTCG report builds the largest meta-analysis so far available. In a 15 year follow-up on 10,801 patients, whole breast irradiation (WBI) halves the average annual rate of disease recurrence (RR 0.52, 0.48–0.56) and reduces the annual breast cancer death rate by about one sixth (RR 0.82, 0.75–0.90), with a similar proportional, but different absolute benefit in prognostic subgroups (EBCTCG 2011).
Furthermore, there is growing evidence that risk-adapted dose augmentation strategies to the tumor bed as well as the implementation of high precision RT techniques (e.g., intraoperative radiotherapy) contribute substantially to a further reduction of local relapse rates. A main focus of ongoing research lies in partial breast irradiation strategies as well as WBI hypofractionation schedules. The potential of both in replacing normofractionated WBI has not yet been finally clarified.
Conclusion
After breast conserving surgery, no subgroup even in low risk patients has yet been identified for whom radiotherapy can be safely omitted without compromising local control and, hence, cancer-specific survival. In most patients, this translates into an overall survival benefit.
Image guidance during highly conformal radiotherapy requires accurate geometric calibration of the moving components of the imager. Due to limited manufacturing accuracy and gravity-induced flex, an ...x-ray imager's deviation from the nominal geometrical definition has to be corrected for. For this purpose a ball bearing phantom applicable for nine degrees of freedom (9-DOF) calibration of a novel cone-beam computed tomography (CBCT) scanner was designed and validated. In order to ensure accurate automated marker detection, as many uniformly distributed markers as possible should be used with a minimum projected inter-marker distance of 10 mm. Three different marker distributions on the phantom cylinder surface were simulated. First, a fixed number of markers are selected and their coordinates are randomly generated. Second, the quasi-random method is represented by setting a constraint on the marker distances in the projections. The third approach generates the ball coordinates helically based on the Golden ratio, ϕ. Projection images of the phantom incorporating the CBCT scanner's geometry were simulated and analysed with respect to uniform distribution and intra-marker distance. Based on the evaluations a phantom prototype was manufactured and validated by a series of flexmap calibration measurements and analyses. The simulation with randomly distributed markers as well as the quasi-random approach showed an insufficient uniformity of the distribution over the detector area. The best compromise between uniform distribution and a high packing fraction of balls is provided by the Golden section approach. A prototype was manufactured accordingly. The phantom was validated for 9-DOF geometric calibrations of the CBCT scanner with independently moveable source and detector arms. A novel flexmap calibration phantom intended for 9-DOF was developed. The ball bearing distribution based on the Golden section was found to be highly advantageous. The phantom showed satisfying results for calibrations of the CBCT scanner and provides the basis for further flexmap correction and reconstruction developments.
Purpose
Gold-marker-based image-guided radiation therapy (IGRT) of the prostate allows to correct for inter- and intrafraction motion and therefore to safely reduce margins for the prostate planning ...target volume (PTV). However, pelvic PTVs, when coadministered in a single plan (registered to gold markers GM), require reassessment of the margin concept since prostate movement is independent from the pelvic bony anatomy to which the lymphatics are usually referenced to.
Methods
We have therefore revisited prostate translational movement relative to the bony anatomy to obtain adequate margins for the pelvic PTVs compensating mismatch resulting from referencing pelvic target volumes to GMs in the prostate. Prostate movement was analyzed in a set of 28 patients (25 fractions each, totaling in 684 fractions) and the required margins calculated for the pelvic PTVs according to Van Herk’s margin formula
M
=
2.5
Σ
+
1.64
σ
′
-
σ
p
.
Results
The overall mean prostate movement relative to bony anatomy was 0.9 ± 3.1, 0.6 ± 3.4, and 0.0 ± 0.7 mm in anterior/posterior (A/P), inferior/superior (I/S) and left/right (L/R) direction, respectively. Calculated margins to compensate for the resulting mismatch to bony anatomy were 9/9/2 mm in A/P, I/S, and L/R direction and 10/11/6 mm if an additional residual error of 2 mm was assumed.
Conclusion
GM-based IGRT for pelvic PTVs is feasible if margins are adapted accordingly. Margins could be reduced further if systematic errors which are introduced during the planning CT were eliminated.
Purpose
Clinical evaluation of an optical three-dimensional surface scanning (3D-SS) system for patient positioning and monitoring during radiotherapy (RT) for breast cancer.
Materials and methods
A ...ceiling-mounted scanner was developed to acquire multiple 3D body surface images and tested in 14 conservatively operated breast cancer patients. A reference skin surface was derived from the planning computed tomography (CT) scan as basis for rigid registration with the surface scans. In addition to electronic portal images (EPIs), optical scans were acquired at three defined time points before and during daily RT. Patient setup was guided by laser alignments and corrected according to EPI findings. The accuracy of the 3D-SS system was validated by comparison of the optical scans to EPIs generated in parallel. Interfraction shifts were investigated by comparison of the first 3D-SS image with the reference body outline. Intrafractional motions were analysed by comparing the three daily surface scans with the first EPI.
Results
Comparison of EPIs and 3D-SS images revealed good accordance (− 0.05 ± 0.94 mm). Analysis of daily patient positions revealed average deviations of 0.4 ± 2.4 mm laterally, 0.3 ± 1.9 mm longitudinally and 0.2 ± 3.3 mm vertically. After 2 weeks, a systematic interfraction shift in patient positioning was noted, particularly in the vertical direction (4.9 ± 0.56 mm), which was attributed to patients progressively relaxing. 3D-SS images showed intrafractional shifts of 1.2 ± 0.7 mm over a time course of 2 min.
Conclusion
Optical surface scanning is a simple, fast and reproducible method for breast cancer patient alignment. Particularly for more sophisticated irradiation techniques, it helps to improve accuracy in patient positioning during radiotherapy without the exposure to additional ionizing radiation.
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