Outcomes of transcatheter aortic valve replacement in patients with history of chest wall irradiation: Propensity matched analysis of five years data from national inpatient sample (2016-2020).

INTRODUCTION: Chest radiotherapy has been utilized to treat intra-thoracic and mediastinal tumors. Chest wall irradiation (C-XRT) survivors frequently develop valvular disease, including aortic stenosis, which eventually requires valve replacement. Previous trials have shown worse outcomes with surgical aortic valve replacement. However, transcatheter aortic valve replacement (TAVR) outcomes-related data in patients with C-XRT is limited. METHODS: The national inpatient sample (NIS) database was queried from 2016 to 2020 to identify adult hospitalizations with TAVR, which were dichotomized based on a history of C-XRT using ICD-10-CM codes. Propensity score matching was performed to derive age, sex, hospital characteristics, and co-morbidities matched controls without a history of C-XRT. The outcomes studied were inpatient mortality and complications, mean length of stay (LOS), and total hospital charge (THC). Multivariate logistic and linear regression were used to analyze the outcomes. RESULTS: Of 296,670 patients who underwent TAVR between 2016 and 2020, 515 had a history of C-XRT. Upon propensity score matching in patients undergoing TAVR, Patients with a history of C-XRT showed significantly lower adjusted odds of in-hospital mortality (adjusted odd ratio [aOR] 0.04, 95 % CI [0.003-0.57], p = 0.017), lower mean LOS by 1.6 days (-1.88 to -1.26 days, p < 0.001) and reduced mean THC (-$74,720, [-$88,784 to -$60,655], p < 0.001). Additionally, patients with C-XRT had significantly lower adjusted odds of inpatient complications, mainly acute myocardial infarction, cerebrovascular events, acute respiratory failure, acute kidney injury, need for vasopressors and cardiopulmonary resuscitation, whereas similar odds of complications, including a requirement of intubation, mechanical ventilation, hemodialysis, and cardiogenic shock. CONCLUSION: Our analysis showed reduced adjusted odds of in-hospital mortality, length of stay, total hospital charges, and inpatient complications in patients undergoing TAVR with a history of C-XRT. TAVR appears to be a safe and viable alternative in this population subgroup.

Post mastectomy radiotherapy for elderly patients with intermediate risk (T1-2N1 OR T3N0) breast cancer: a systematic review and meta-analysis.

BACKGROUND: To determine if PMRT for elderly patients (>65 years old) with intermediate risk breast cancer (T1-2N1, T3N0) improves outcomes. METHODS: We performed a systematic review and meta-analysis to compare the effects of PMRT to no PMRT for elderly patients with intermediate-risk breast cancer. We searched PubMed for eligible studies from Jan 2008 to Dec 2018. We assessed the methodological quality of the included studies using the ROBINS-I tool and performed the meta-analysis with random effects model. The primary outcome of interest was overall survival (OS); secondary outcomes were breast cancer specific survival (BCSS), loco-regional (LRR) and distant disease recurrence (DDR). RESULTS: We found 2 retrospective cohort studies with 743 patients directly comparing PMRT to no PMRT. Both studies were judged to have serious risk of bias in their methodological quality. The pooled results suggest that PMRT was associated with a 20% relative reduction in the hazard in death, ranging from 41% relative reduction, a substantial negative association to 10% relative increase, a small positive association (HR 0.80, 95% CI: 0.59-1.1, P=0.62, I2=0%). PMRT was also associated with a 17% relative reduction in the hazard for breast cancer related death, ranging from 52% relative reduction, a substantial negative association to 41% relative increase, a substantial positive association (HR 0.83, 95% CI: 0.48-1.41, P=0.48, I2=0%). One study did not observe any significant differences in LRR and DDR between the two groups. CONCLUSIONS: The survival benefits from PMRT in unselected elderly patients with intermediate risk breast cancer is unclear. Further research to better select elderly patients who may benefit from PMRT is warranted. Patients with a multiple pathological risk factors suggestive of high risk of loco-regional recurrence post-mastectomy should consider PMRT.

Dosimetric comparison between volumetric-modulated arc therapy and a hybrid volumetric-modulated arc therapy and segmented field-in-field technique for postmastectomy chest wall and regional lymph node irradiation.

Decreasing radiotoxicity to the heart, lungs, and contralateral breast has proven to lower the risk of secondary malignancy and improve overall outcomes when treating chest wall (CW) and regional lymph nodes in postmastectomy breast cancer patients. In this retrospective study, 11 postmastectomy patients were selected and planned with a novel hybrid treatment method and a traditional volumetric arc therapy (VMAT) approach for comparison. This hybrid technique was able to optimize tangential beams to minimize heart dose and the VMAT contribution to improve dose conformity around the planning target volume (PTV). Overall, this hybrid technique produced more homogenous target dose coverage and demonstrated a decrease of integral dose to organs at risk (OAR), while the VMAT technique demonstrated a higher affinity for maintaining dose conformity. Further observation of dose distributions also revealed that the hybrid plans were more effective in sparing low-dose spread to healthy tissue in both right- and left-sided cases. This observation was made evident by the reduction in heart V5 and Dmean, decreases in all parameters regarding the contralateral lung, as well as all values other than the V20 of the ipsilateral lung. This unique hybrid planning technique could present an alternative to standard intensity-modulated radiation therapy (IMRT) planning when treating postmastectomy CW and regional lymph nodes, as it has shown the capacity to decrease cardiac, lung, and contralateral breast toxicity while maintaining quality PTV coverage.

Dosimetric comparison of three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for left-sided chest wall and lymphatic irradiation.

INTRODUCTION: The aim of this study was to compare five different techniques for chest wall (CW) and lymphatic irradiation in patients with left-sided breast carcinoma. METHODS: Three-dimensional conformal radiotherapy (3DCRT), forward-planned intensity-modulated radiotherapy (FP-IMRT), inverse-planned IMRT (IP-IMRT; 7- or 9-field), and hybrid IP-/FP-IMRT were compared in 10 patients. Clinical target volume (CTV) included CW and internal mammary (IM), supraclavicular (SC), and axillary nodes. Planning target volumes (PTVs), CTVs, and organs at risks (OARs) doses were analyzed with dose-volume histograms (DVHs). RESULTS: No differences could be observed among the techniques for doses received by 95% of the volume (D95%) of lymphatics. However, the FP-IMRT resulted in a significantly lower D95% dose to the CW-PTV compared to other techniques (P = 0.002). The 9-field IP-IMRT achieved the lowest volumes receiving higher doses (hotspots). Both IP-IMRT techniques provided similar mean doses (Dmean) for the left lung which were smaller than the other techniques. There was no difference between the techniques for maximum dose (Dmax) of right breast. However, FP-IMRT resulted in lower Dmean and volume of right breast receiving at least 5 Gy doses compared to other techniques. CONCLUSION: The dose homogeneity in CW-CTV was better using IMRT techniques compared to 3DCRT. Especially 9-field IP-IMRT provided a more homogeneous dose distribution in IM and axillary CTVs. Moreover, the OARs volumes receiving low radiation doses were larger with IP-IMRT technique, while volumes receiving high radiation doses were larger with FP-IMRT technique. Hybrid IMRT plans were found to have the advantages of both FP- and IP-IMRT techniques.

[Locoregional control and patterns of locoregional failure in women with breast cancer treated by highly conformal electron beam irradiation]. / Caractérisation des rechutes locorégionales chez des patientes atteintes d'un cancer du sein traité par irradiation pariétale par électrons : expérience monocentrique de l'institut Curie.

PURPOSE: The purpose of this study was to evaluate locoregional control and describe the patterns of locoregional failure in women with breast cancer irradiated by a previously described post-mastectomy highly conformal electron beam radiotherapy technique. MATERIAL AND METHODS: We included all women irradiated by post-mastectomy highly conformal electron beam radiotherapy technique for non-metastatic breast cancer between 2007 and 2011 in our department. All cases of bilateral breast cancer were excluded. All patients who experienced locoregional recurrence have been studied. Mapping patterns of regional recurrences was also performed and compared with the European Society for Radiotherapy and Oncology (ESTRO) and Radiotherapy Oncology Group (RTOG) guidelines of volume definition and delineation guidelines. RESULTS: With a median follow-up of 64 months (range: 6-102 months), 5-year locoregional recurrence-free and overall survival probabilities were 90 % (95 % confidence interval [95 %CI]: 88.1-92.4) and 90.9 % (95 %CI: 88.9-93), respectively. Among the 796 patients included in the study, 23 patients (2.9 %) presented locoregional recurrences of them only 13 (1.6%) were presented with local recurrence. The majority of them presented aggressive biological features with grade III tumours in 17 patients (74 %) with high mitotic index in 16 cases (70 %) and triple negative tumours in 12 (52 %). Lymphovascular invasion was observed in 11 cases (48 %). In 14 cases the locoregional recurrences were diagnosed at the same time as the metastatic disease whereas 4 patients presented distant metastases secondarily. Locoregional recurrences occurred in 11 cases "in field" although adequate doses and volumes were used and in 12 cases "outfield", out of irradiated volume. Local recurrences occurred in 13 patients with 12 recurrences within the irradiated volumes. Regional recurrences occurred in 13 patients with 15 lymph nodes metastases identified. Four nodal recurrences occurred outside the ESTRO clinical target volume and within the RTOG clinical target volume and two occurred outside both RTOG and ESTRO clinical target volumes. CONCLUSION: In presented series, the local recurrence resulted mostly from of biologic radio resistance whereas regional recurrences were caused by geographical miss. A number of nodal recurrences could occur outside the target volumes defined by ESTRO and RTOG.

Chest wall recurrence in pT1-2N0-1 breast cancer patients after mastectomy without radiotherapy.

PURPOSE: In correlation with the nodal status in the era of modern radiotherapy, the chest wall recurrence (CWR) rate was investigated in pT1-2N0-1 breast cancer patients after a mastectomy without post-mastectomy radiotherapy (PMRT). METHODS: The data from the patients participating in two South Korean multi-institutional studies (KROG 14-22; N = 1842 and KROG 14-23; N = 1382) were analyzed. In total, 3224 pT1-2N0-1 breast cancer patients who underwent mastectomy without PMRT were analyzed. RESULTS: The median follow-up time was 72.2 months (range 0.8-125.2 months). The overall CWRs during the follow-up period were 1.68% in N0 patients and 2.82% in N1 patients. There was no statistically significant difference in 5-year and 10-year CWR-free survival (CWRFS) between the N0 and N1 patients. Of the 70 patients with CWR, 33 (1% of all the patients) had isolated CWR, and the 10-year overall survival rate in this group was 96.9%. After the propensity score matching of the N0 and N1 groups, there was still no difference in CWRFS by nodal status. CONCLUSIONS: The incidence of CWR in pT1-2N0-1 breast cancer patients is very low, especially with isolated recurrence. Also, the obtained data showed that the nodal status had no impact on CWRFS.

Electron postmastectomy chest wall plus comprehensive nodal irradiation technique using Electron Monte Carlo dose algorithm.

For left-sided postmastectomy patients requiring chest wall plus comprehensive nodal irradiation, sometimes traditional techniques such as partial wide tangents or electron/tangents combination are not feasible due to abnormal chest wall contour or heart position or unusually wide excision scar. We developed electron chest wall irradiation technique using Electron Monte Carlo (EMC) dose algorithm that will achieve heart sparing with acceptable ipsilateral lung dose, minimal contralateral lung, and breast dose. Ten left-sided postmastectomy patients with very challenging anatomy were selected for this dosimetry study. The en face electron fields were designed from a single isocenter and gantry angle with different energy beams using different cutouts that matched on the skin. Smaller energy was used in the central thin chest wall part and higher energy in the medial internal mammary nodes (IMN) area, superior part of the thick chest wall, and/or axillary nodal area. The electron fields were matched to the photon supraclavicular field in the superior region. Daily field junctions were used to feather the match lines between all the fields. Electron field dose calculations were done with Monte Carlo. Five patients' chest wall fields were planned with 6/9MeVcombination, 1 with 6/12 MeV, 2 with 9/12 MeV, 1 with 9/16 MeV, and 1 with 6/9/12 MeV. Institutional criteria of prescription dose of 50 Gy for target volumes and normal tissue dose were met with this technique in spite of the challenging anatomy. Mean heart dose averaged 3.0 Gy ± 0.8 Gy. For ipsilateral lung, V20Gy and V5Gy averaged 33.2% ± 4.5% and 64.6% ± 9.6%, respectively. For contralateral lung, V5Gy averaged 5.1% ± 5.0%. For contralateral breast, V5Gy averaged 3.3% ± 3.1%. The electron chest wall irradiation technique using EMC dose algorithm can provide adequate dose coverage to the chest wall, IMNs, and/or axillary nodes while achieving heart sparing with acceptable ipsilateral lung dose, minimal contralateral lung, and breast dose.

Revision of orthovoltage chest wall treatment using Monte Carlo simulations.

PURPOSE: Given the high local control rates observed in breast cancer patients undergoing chest wall irradiation by kilovoltage x-rays, we aimed to revisit this treatment modality by accurate calculation of dose distributions using Monte Carlo simulation. METHODS AND MATERIAL: The machine components were simulated using the MCNPX code. This model was used to assess the dose distribution of chest wall kilovoltage treatment in different chest wall thicknesses and larger contour or fat patients in standard and mid sternum treatment plans. Assessments were performed at 50 and 100 cm focus surface distance (FSD) and different irradiation angles. In order to evaluate different plans, indices like homogeneity index, conformity index, the average dose of heart, lung, left anterior descending artery (LAD) and percentage target coverage (PTC) were used. Finally, the results were compared with the indices provided by electron therapy which is a more routine treatment of chest wall. RESULT: These indices in a medium chest wall thickness in standard treatment plan at 50 cm FSD and 15 degrees tube angle was as follows: homogeneity index 2.57, conformity index 7.31, average target dose 27.43 Gy, average dose of heart, lung and LAD, 1.03, 2.08 and 1.60 Gy respectively and PTC 11.19%. Assessments revealed that dose homogeneity in planning target volume (PTV) and conformity between the high dose region and PTV was poor. To improve the treatment indices, the reference point was transferred from the chest wall skin surface to the center of PTV. The indices changed as follows: conformity index 7.31, average target dose 60.19 Gy, the average dose of heart, lung and LAD, 3.57, 6.38 and 5.05 Gy respectively and PTC 55.24%. Coverage index of electron therapy was 89% while it was 22.74% in the old orthovoltage method and also the average dose of the target was about 50 Gy but in the given method it was almost 30 Gy. CONCLUSION: The results of the treatment study show that the optimized standard and mid sternum treatment for different chest wall thicknesses is with 50 cm FSD and zero (vertical) tube angle, while in large contour patients, it is with 100 cm FSD and zero tube angle. Finally, chest wall kilovoltage and electron therapies were compared, which revealed that electron therapy produces a better dose distribution than kilovoltage therapy.

In vivo skin dose measurement using MOSkin detectors in tangential breast radiotherapy.

The purpose of this study is to measure patient skin dose in tangential breast radiotherapy. Treatment planning dose calculation algorithm such as Pencil Beam Convolution (PBC) and in vivo dosimetry techniques such as radiochromic film can be used to accurately monitor radiation doses at tissue depths, but they are inaccurate for skin dose measurement. A MOSFET-based (MOSkin) detector was used to measure skin dose in this study. Tangential breast radiotherapies ("bolus" and "no bolus") were simulated on an anthropomorphic phantom and the skin doses were measured. Skin doses were also measured in 13 patients undergoing each of the techniques. In the patient study, the EBT2 measurements and PBC calculation tended to over-estimate the skin dose compared with the MOSkin detector (p<0.05) in the "no bolus radiotherapy". No significant differences were observed in the "bolus radiotherapy" (p>0.05). The results from patients were similar to that of the phantom study. This shows that the EBT2 measurement and PBC calculation, while able to predict accurate doses at tissue depths, are inaccurate in predicting doses at build-up regions. The clinical application of the MOSkin detectors showed that the average total skin doses received by patients were 1662±129cGy (medial) and 1893±199cGy (lateral) during "no bolus radiotherapy". The average total skin doses were 4030±72cGy (medial) and 4004±91cGy (lateral) for "bolus radiotherapy". In some cases, patient skin doses were shown to exceed the dose toxicity level for skin erythema. Hence, a suitable device for in vivo dosimetry is necessary to accurately determine skin dose.

Refractory recurrent bleeding as a late mortal complication of chest wall irradiation.

Radiation therapy is used to treat breast malignancies. Old external radiotherapy protocols included high-dose schedules and were associated with late complications. We describe the case of a 72-year-old woman who was admitted with recurrent bleeding from chest wall. Arteriovenous fistulae were diagnosed. Embolization therapy was initially successful, even though the bleeding episodes became recurrent. Arteriovenous fistulae should be included among differential diagnosis of thoracic bleeding in patients with history of local radiation therapy. The prognosis is poor and endovascular treatment may be considered a first-line treatment.

Dosimetric study of three different kinds of radiotherapy technique for post-operative breast cancer / 中华放射医学与防护杂志

Objective To investigate the dosimetric characteristics of helical tomotherapy(HT),intensity-modulated radiation therapy(IMRT)and three.dimensional conformal radiation therapy(3D-CRT)for the post-operative breast cancer as well as their comparison in protecting the normal tissues.Methods The CT images of 10 postoperative patients with early stage breast cancer were transferRed into HT and IMRT and 3D- CRT planning system respectively after the target region and normal tissues were drawn out with the same doctor.Each prescribed dose for three kinds of plans was 50 Gy/25 fractions.Inrradiation doses and volume at heart and double lungs as well as conformity index(CI)and homogeneity index(HI)were evaluated.Results The PTV volume of prescribed target dose of 95% and 100%in HT, IMRT and 3D-CRT groups were 99.13%and 95.87%,97.80%and 94.05%,96.37%and 87.29%.respectively.The CI and HI in HT.IMRT and 3D-CRT groups were 0.80±0.10 and 1.09 ±0.03,0.65±0.07 and 1.14±0.02,0.40±0.08 and 1.17±0.04,respectively V5,V10 and V20 of the heart were the lowest at 3D-CRT than HT and lM RT.V5 of the diseased lung was the lowest at 3D-CRT compared to HT and IMRT.V5 and V10 of the healthy lung were the lowest at 3 D-CRT compared to other groups.Conclusions Compared with IMRT and 3D-CRT.HT technique in treating breast cancer had the best conformity index and homogeneity index as well as steeper dose gradient.Irradiated doses and volume at the heart was the lowest at 3D- CRT and the highest at IMRT.Irradiated doses and volume of the heart and healthy lung as well as the diseased lung were the lowest at 3D-CRT compared to HT and IMRT groups.