International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationProne Whole-Breast Irradiation Using Three-Dimensional Conformal Radiotherapy in Women Undergoing Breast Conservation for Early Disease Yields High Rates of Excellent to Good Cosmetic Outcomes in Patients With Large and/or Pendulous Breasts
Introduction
The majority of patients with early-stage breast cancer are candidates for breast-conservation therapy (BCT). Several large randomized control trials comparing BCT with mastectomy have demonstrated no difference in locoregional control, disease-free survival, or overall survival (1). These large studies have all been conducted using whole-breast irradiation (WBI) delivered in the supine position. However, supine breast WBI does have limitations. Irradiation after breast-conserving surgery (BCS) in women with large and/or pendulous breasts can be particularly challenging. Several institutions have shown increased radiation-related toxicities and worse cosmetic outcomes for patients with large, pendulous breasts and/or increased body mass index (BMI) undergoing BCT 2, 3, 4, 5, 6, 7, 8, 9. Radiation factors identified as potentially causative include increased dose inhomogeneity from medial to lateral separation of the breast and bolus effect on skin, including the inframammary folds, where there is increased skin-on-skin contact. In addition, patients with large breasts may receive increased doses to critical structures such as the heart or lungs owing to the positioning of the breast on the chest wall when the patient lies supine. Prone breast irradiation aims to improve on some of the technical limitations associated with treating large, pendulous breasts and/or large body habitus, and it may also assist in limiting radiation doses to organs at risk 10, 11, 12, 13, 14, 15.
Our institution developed a method for delivering breast three-dimensional conformal radiotherapy (3D-CRT) in the prone position to address the technical challenges associated with irradiation of large and/or pendulous breasts. The goal of this study was to report our institution's experience using prone positioning in a cohort of women receiving postlumpectomy WBI, to determine the rate of acute and late toxicities and, more specifically, cosmetic outcomes. We hypothesized that the use of 3D-CRT for WBI in the prone position would reduce or eliminate patient and breast size as negative prognostic indicators for toxicities associated with WBI.
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Study population
Between 1998 and 2006, 109 women (110 breasts treated) underwent WBI in the prone position using 3D-CRT. One patient had a history of Hodgkin's disease treated with radiation to the mediastinum. All other patients were treated prone secondary to a large body habitus and/or large–pendulous breasts. The median follow-up was 40.3 months (mean 45.9 months, range 1–127 months) for living patients. One hundred five patients had 1 year or more of clinical follow-up (median 43.1 months, mean 47.4
Study population
The individual characteristics of the patient population are summarized in Table 1. Median age of the patients (n = 110 cases) was 61.0 years. Seventy-five percent of patients were clinically obese (BMI ≥30 kg/m2), with a median and mean BMI of 33.6 kg/m2 and 34.6 kg/m2, respectively. The majority of patients also had large and/or pendulous breasts, with a median breast volume of 1396 cm3 and 80% of patients with breast volumes of ≥1000 cm3.
Tumor and treatment characteristics
Table 1 summarizes the tumor and treatment
Discussion
Breast-conserving treatment has allowed many women to receive appropriate breast cancer management with long-term local control and survival rates equivalent to those with mastectomy, while maintaining a cosmetically acceptable breast appearance. Unfortunately, women with larger breasts can be technically challenging to treat with breast irradiation, resulting in higher rates of severe acute dermatitis and late fibrosis causing unacceptable cosmesis. Our institution has developed prone breast
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ESTRO-ACROP guideline for positioning, immobilisation and setup verification for local and loco-regional photon breast cancer irradiation
2023, Technical Innovations and Patient Support in Radiation OncologyAdvances in Radiotherapy for Breast Cancer
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2023, Surgical Clinics of North AmericaCitation Excerpt :For individuals with breast cancer, a deep inspiratory breath hold (DIBH) technique increases the distance between the heart and the breast/chest wall to minimize cardiac radiation dose.2 A prone setup technique can be conducted for patients with larger, pendulous breasts to limit skin reactions while also potentially minimizing dose to the lung and heart.3 The CT image sets are sent to the treatment planning system computer.
Challenges and impact of patient obesity in radiation therapy practice
2020, RadiographyCitation Excerpt :This is both an issue for the ‘average’ sized patient with pendulous breasts, but specifically for obese patients because of increased patient size, distribution of adiposity and wider girth that must fit through the CT bore which is generally 80 cm in maximum diameter in RT departments. A study of 110 patients with median BMI of 34 treated with whole breast irradiation showed the prone position had favourable toxicity profiles and excellent cosmesis.28 In other studies, the prone position has been reported as unfavourable for obese patients due to difficulties getting the patients onto the breast board and worse reproducibility.27
Prevalence of pain in patients with breast cancer post-treatment: A systematic review
2018, BreastCitation Excerpt :In the remaining 45 studies (25.4%), evaluating the incidence of pain was not the primary focus. Twenty-three studies (13.6%) explored the efficacy of different radiation techniques and associated outcomes [15–37]; 7 studies (4.0%) focused on quality of life (QoL) [38–44]; 7 articles (4.0%) assessed the efficacy of intervention or rescue treatments [45–51]; 1 study (0.6%) reported on skin toxicities and cosmesis outcomes post-radiotherapy [52]; 3 (1.7%) evaluated the prognostic significance of symptoms as predictors [53–55]; 3 (1.7%) reported on the validation or effectiveness of screening tools [56–58]; and 1 study (0.6%) compared symptom-reporting between patient and physician post-radiotherapy [59]. One hundred seventy-seven studies described pain prevalence and severity post-BC therapy (Table 11).
Supported in part by Grant No. 1UL1RR031973 from the Clinical and Translational Science Award program of the National Center for Research Resources, National Institutes of Health.
Conflict of interest: none.