Radiotherapy & Oncology
Volume 94, Issue 3 , Pages 255-263 , March 2010

Target volume definition for external beam partial breast radiotherapy: Clinical, pathological and technical studies informing current approaches

  • Anna M. Kirby

      Affiliations

    • Royal Marsden NHS Foundation Trust, Sutton, UK
    • Corresponding Author InformationCorresponding author.
  • ,
  • Charlotte E. Coles

      Affiliations

    • Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  • ,
  • John R. Yarnold

      Affiliations

    • Institute of Cancer Research, Sutton, UK

Received 22 October 2009 ,Revised 3 December 2009 ,Accepted 17 December 2009.

References 

  1. Orecchia R, Ciocca M, Lazzari R, et al. Intraoperative radiation therapy with electrons (ELIOT) in early-stage breast cancer. Breast. 2003;12:483–490
  2. Vaidya JS. Partial breast irradiation using targeted intraoperative radiotherapy (Targit). Nat Clin Pract Oncol. 2007;4:384–385
  3. Strnad V, Polgar C. On behalf of the European Brachytherapy Breast Cancer GEC-ESTRO Working Group. GEC-ESTRO APBI Trial: Interstitial brachytherapy alone versus external beam radiation therapy after breast conserving surgery for low risk invasive carcinoma and low risk duct carcinoma in situ (DCIS) of the female breast; 2006. <http://www.abpi.uni-erlangen.de/outline/outline.html>.
  4. Wolmark N, Curran WJ. On behalf of NSABP and RTOG of the American College of Radiology NSABP Protocol B-39. RTOG Protocol 0413. A randomized study phase III study of conventional whole breast irradiation versus partial breast irradiation for women with stage 0, I or II breast cancer. National surgical adjuvant breast and bowel project; 13 March, 2007. p. 1–132.
  5. OCOG. Ontario Clinical Oncology Group, Canadian Institutes of Health Research, Canadian Breast Cancer Research Alliance. RAPID: randomized trial of accelerated partial breast irradiation; 2008. <http://clinicaltrials.gov/ct2/show/NCT00282035>.
  6. Yarnold J, Coles C. On behalf of the IMPORT-Low Trial Management Group. Intensity-Modulated and Partial Organ Radiotherapy. Randomised trial testing intensity-modulated and partial organ radiotherapy following breast conservation surgery for early breast cancer. Trial Protocol, version 6, 2009, Institute of Cancer Research, Sutton, UK. p.1–74.
  7. <http://groups.eortc.be/radio/res/irma/synopsis_trial_irma1.pdf>.
  8. Danish Breast Cancer Co-operative Group. Partial breast versus whole breast irradiation in elderly women operated on for early breast cancer. clinicaltrials.gov/ct2/show/NCT00892814.
  9. Smith BD, Arthur DW, Buchholz TA, et al. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys. 2009;74:987–1001
  10. Mannino M, Yarnold J. Accelerated partial breast irradiation trials: diversity in rationale and design. Radiother Oncol. 2009;91:16–22
  11. Sher DJ, Wittenberg E, Suh WW, Taghian AG, Punglia RS. Partial-breast irradiation versus whole-breast irradiation for early-stage breast cancer: a cost-effectiveness analysis. Int J Radiat Oncol Biol Phys. 2009;74:440–446
  12. ICRU Report 50. Prescribing, recording and reporting photon beam therapy. Maryland: Bethseda; 1993.
  13. ICRU Report 62. Prescribing, recording and reporting photon beam therapy (Supplement to ICRU Report 50). Maryland: Bethseda; 1999.
  14. Machtay M, Lanciano R, Hoffman J, Hanks GE. Inaccuracies in using the lumpectomy scar for planning electron boosts in primary breast carcinoma. Int J Radiat Oncol Biol Phys. 1994;30:43–48
  15. Bedwinek J. Breast conserving surgery and irradiation: the importance of demarcating the excision cavity with surgical clips. Int J Radiat Oncol Biol Phys. 1993;26:675–679
  16. Harrington KJ, Harrison M, Bayle P, et al. Surgical clips in planning the electron boost in breast cancer: a qualitative and quantitative evaluation. Int J Radiat Oncol Biol Phys. 1996;34:579–584
  17. Krawczyk JJ, Engel B. The importance of surgical clips for adequate tangential beam planning in breast conserving surgery and irradiation. Int J Radiat Oncol Biol Phys. 1999;43:347–350
  18. Landis DM, Luo W, Song J, et al. Variability among breast radiation oncologists in delineation of the postsurgical lumpectomy cavity. Int J Radiat Oncol Biol Phys. 2007;67:1299–1308
  19. Paterson ML, Nathanson SD, Havstad S. Hematomas following excisional breast biopsies for invasive breast carcinoma: the influence of deep suture approximation of breast parenchyma. Am Surg. 1994;60:845–848
  20. Indelicato D, Grobmyer SR, Newlin H, et al. Association between operative closure type and acute infection, local recurrence, and disease surveillance in patients undergoing breast conserving therapy for early-stage breast cancer. Surgery. 2007;141:645–653
  21. Holmberg L, Zaren E, Adami HO, Bergstrom R, Burns T. The patient’s appraisal of the cosmetic result of segmental mastectomy in benign and malignant breast disease. Ann Surg. 1988;207:189–194
  22. Rabinovitch R, Finlayson C, Pan Z, et al. Radiographic evaluation of surgical clips is better than ultrasound for defining the lumpectomy cavity in breast boost treatment planning: a prospective clinical study. Int J Radiat Oncol Biol Phys. 2000;47:313–317
  23. Coles CE, Cash CJ, Treece GM, et al. High definition three-dimensional ultrasound to localise the tumour bed: a breast radiotherapy planning study. Radiother Oncol. 2007;84:233–241
  24. Whipp EC, Halliwell M. Magnetic resonance imaging appearances in the postoperative breast: the clinical target volume-tumor and its relationship to the chest wall. Int J Radiat Oncol Biol Phys. 2008;72:49–57
  25. Frei KA, Kinkel K, Bonel HM, Lu Y, Esserman LJ, Hylton NM. MR imaging of the breast in patients with positive margins after lumpectomy: influence of the time interval between lumpectomy and MR imaging. AJR Am J Roentgenol. 2000;175:1577–1584
  26. Anderson BO, Masetti R, Silverstein MJ. Oncoplastic approaches to partial mastectomy: an overview of volume–displacement techniques. Lancet Oncol. 2005;6:145–157
  27. Kader HA, Truong PT, Pai R, et al. When is CT-based postoperative seroma most useful to plan partial breast radiotherapy? Evaluation of clinical factors affecting seroma volume and clarity. Int J Radiat Oncol Biol Phys. 2008;72:1064–1069
  28. Ford E, Lavely W, Frassica D, Myers L, Asrari F, Wahl R, et al. Comparison of PET/CT and CT for delineation of lumpectomy cavity for partial breast irradiation. Int J Radiat Oncol Biol Phys. 2006;66:S225–226
  29. Sabine B, Giovanna D, Peter P, Clara J, Bert P, John K. Open low-field magnetic resonance (MR) versus CT scanner (CT) imaging in breast radiotherapy treatment planning. Int J Radiat Oncol Biol Phys. 2005;63:S232–S233
  30. Ringash J, Whelan T, Elliott E, et al. Accuracy of ultrasound in localization of breast boost field. Radiother Oncol. 2004;72:61–66
  31. Coles CE, Wilson CB, Cumming J, et al. Titanium clip placement to allow accurate tumour bed localisation following breast conserving surgery: audit on behalf of the IMPORT Trial Management Group. Eur J Surg Oncol. 2009;35:578–582
  32. Kass R, Kumar G, Klimberg VS, et al. Clip migration in stereotactic biopsy. Am J Surg. 2002;184:325–331
  33. Weed DW, Yan D, Martinez AA, Vicini FA, Wilkinson TJ, Wong J. The validity of surgical clips as a radiographic surrogate for the lumpectomy cavity in image-guided accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys. 2004;60:484–492
  34. Kirby AM, Yarnold JR, Evans PM, et al. Tumor bed delineation for partial breast and breast boost radiotherapy planned in the prone position: what does MRI add to X-ray CT localization of titanium clips placed in the excision cavity wall?. Int J Radiat Oncol Biol Phys. 2009;74:1276–1282
  35. Kokubo M, Mitsumori M, Yamamoto C, et al. Impact of boost irradiation with surgically placed radiopaque clips on local control in breast-conserving therapy. Breast Cancer. 2001;8:222–228
  36. Association of Breast Surgery at Baso 2009. Surgical guidelines for the management of breast cancer. Eur J Surg Oncol 2009;35(Suppl. 1):1–22.
  37. Goldberg H, Prosnitz RG, Olson JA, Marks LB. Definition of postlumpectomy tumor bed for radiotherapy boost field planning: CT versus surgical clips. Int J Radiat Oncol Biol Phys. 2005;63:209–213
  38. Hurkmans C, Admiraal M, Van der Sangen M, Dijkmans I. Significance of breast boost volume changes during radiotherapy in relation to current clinical interobserver variations. Radiother Oncol. 2009;90:60–65
  39. Clark RM, Whelan T, Levine M, et al. Randomized clinical trial of breast irradiation following lumpectomy and axillary dissection for node-negative breast cancer: an update. Ontario Clinical Oncology Group. J Natl Cancer Inst. 1996;88:1659–1664
  40. Fisher B, Anderson S, Bryant J, 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;347:1233–1241
  41. Veronesi U, Marubini E, Mariani L, et al. Radiotherapy after breast-conserving surgery in small breast carcinoma: long-term results of a randomized trial. Ann Oncol. 2001;12:997–1003
  42. Liljegren G, Holmberg L, Bergh J, et al. 10-Year results after sector resection with or without postoperative radiotherapy for stage I breast cancer: a randomized trial. J Clin Oncol. 1999;17:2326–2333
  43. Malmstrom P, Holmberg L, Anderson H, et al. Breast conservation surgery, with and without radiotherapy, in women with lymph node-negative breast cancer: a randomised clinical trial in a population with access to public mammography screening. Eur J Cancer. 2003;39:1690–1697
  44. Krauss DJ, Kestin LL, Mitchell C, Martinez AA, Vicini FA. Changes in temporal patterns of local failure after breast-conserving therapy and their prognostic implications. Int J Radiat Oncol Biol Phys. 2004;60:731–740
  45. Huang E, Buchholz TA, Meric F, et al. Classifying local disease recurrences after breast conservation therapy based on location and histology: new primary tumors have more favorable outcomes than true local disease recurrences. Cancer. 2002;95:2059–2067
  46. Kurtz JM, Amalric R, Brandone H, et al. Local recurrence after breast-conserving surgery and radiotherapy. Frequency, time course, and prognosis. Cancer. 1989;63:1912–1917
  47. Recht A, Silen W, Schnitt SJ, et al. Time-course of local recurrence following conservative surgery and radiotherapy for early stage breast cancer. Int J Radiat Oncol Biol Phys. 1988;15:255–261
  48. Veronesi U, Marubini E, Del Vecchio M, et al. Local recurrences and distant metastases after conservative breast cancer treatments: partly independent events. J Natl Cancer Inst. 1995;87:19–27
  49. Smith TE, Lee D, Turner BC, Carter D, Haffty BG. True recurrence vs. new primary ipsilateral breast tumor relapse: an analysis of clinical and pathologic differences and their implications in natural history, prognoses, and therapeutic management. Int J Radiat Oncol Biol Phys. 2000;48:1281–1289
  50. Freedman GM, Anderson PR, Hanlon AL, Eisenberg DF, Nicolaou N. Pattern of local recurrence after conservative surgery and whole-breast irradiation. Int J Radiat Oncol Biol Phys. 2005;61:1328–1336
  51. Bartelink H, Horiot JC, Poortmans PM, et al. Impact of a higher radiation dose on local control and survival in breast-conserving therapy of early breast cancer: 10-year results of the randomized boost versus no boost EORTC 22881–10882 trial. J Clin Oncol. 2007;25:3259–3265
  52. Offersen BV, Overgaard M, Kroman N, Overgaard J. Accelerated partial breast irradiation as part of breast conserving therapy of early breast carcinoma: a systematic review. Radiother Oncol. 2009;90:1–13
  53. Holland R, Veling SH, Mravunac M, Hendriks JH. Histologic multifocality of Tis, T1-2 breast carcinomas. Implications for clinical trials of breast-conserving surgery. Cancer. 1985;56:979–990
  54. Vicini FA, Kestin LL, Goldstein NS. Defining the clinical target volume for patients with early-stage breast cancer treated with lumpectomy and accelerated partial breast irradiation: a pathologic analysis. Int J Radiat Oncol Biol Phys. 2004;60:722–730
  55. Gennaro M, Ferraris C, Guida V, Tomasic G, Carcangiu ML, Greco M. Conservative surgery in breast cancer. Significance of resection margins. Breast. 2001;10:432–437
  56. Vicini FA, Kestin L, Chen P, Benitez P, Goldstein NS, Martinez A. Limited-field radiation therapy in the management of early-stage breast cancer. J Natl Cancer Inst. 2003;95:1205–1210
  57. Formenti SC, Truong MT, Goldberg JD, et al. Prone accelerated partial breast irradiation after breast-conserving surgery: preliminary clinical results and dose–volume histogram analysis. Int J Radiat Oncol Biol Phys. 2004;60:493–504
  58. Vicini FA, Chen P, Wallace M, et al. Interim cosmetic results and toxicity using 3D conformal external beam radiotherapy to deliver accelerated partial breast irradiation in patients with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys. 2007;69:1124–1130
  59. Hanbeukers B, Borger J, Van den Ende P, et al. Customized computed tomography-based boost volumes in breast-conserving therapy: use of three-dimensional histologic information for clinical target volume margins. Int J Radiat Oncol Biol Phys. 2009;75:757–763
  60. Stroom J, Schlief A, Alderliesten T, Peterse H, Bartelink H, Gilhuijs K. Using histopathology breast cancer data to reduce clinical target volume margins at radiotherapy. Int J Radiat Oncol Biol Phys. 2009;74:898–905
  61. Fisher ER, Sass R, Fisher B, Gregorio R, Brown R, Wickerham L. Pathologic findings from the National Surgical Adjuvant Breast Project (protocol 6). II. Relation of local breast recurrence to multicentricity. Cancer. 1986;57:1717–1724
  62. Faverly DR, Hendriks JH, Holland R. Breast carcinomas of limited extent: frequency, radiologic–pathologic characteristics, and surgical margin requirements. Cancer. 2001;91:647–659
  63. Vaidya JS, Vyas JJ, Chinoy RF, Merchant N, Sharma OP, Mittra I. Multicentricity of breast cancer: whole-organ analysis and clinical implications. Br J Cancer. 1996;74:820–824
  64. Moffat DF, Going JJ. Three dimensional anatomy of complete duct systems in human breast: pathological and developmental implications. J Clin Pathol. 1996;49:48–52
  65. Salvadori B, Marubini E, Miceli R, et al. Reoperation for locally recurrent breast cancer in patients previously treated with conservative surgery. Br J Surg. 1999;86:84–87
  66. Forrest AP, Stewart HJ, Everington D, et al. Randomised controlled trial of conservation therapy for breast cancer: 6-year analysis of the Scottish trial. Scottish Cancer Trials Breast Group. Lancet. 1996;348:708–713
  67. Fisher B, Bryant J, Dignam JJ, et al. Tamoxifen, radiation therapy, or both for prevention of ipsilateral breast tumor recurrence after lumpectomy in women with invasive breast cancers of one centimeter or less. J Clin Oncol. 2002;20:4141–4149
  68. Winzer KJ, Sauer R, Sauerbrei W, et al. Radiation therapy after breast-conserving surgery; first results of a randomised clinical trial in patients with low risk of recurrence. Eur J Cancer. 2004;40:998–1005
  69. Potter R, Gnant M, Kwasny W, et al. Lumpectomy plus tamoxifen or anastrozole with or without whole breast irradiation in women with favorable early breast cancer. Int J Radiat Oncol Biol Phys. 2007;68:334–340
  70. Ohtake T, Abe R, Kimijima I, et al. Intraductal extension of primary invasive breast carcinoma treated by breast-conservative surgery. Computer graphic three-dimensional reconstruction of the mammary duct-lobular systems. Cancer. 1995;76:32–45
  71. Love SM, Barsky SH. Breast-duct endoscopy to study stages of cancerous breast disease. Lancet. 1996;348:997–999
  72. Dooley WC. Routine operative breast endoscopy during lumpectomy. Ann Surg Oncol. 2003;10:38–42
  73. Simonetti F, Huang L, Duric N, Littrup P. Diffraction and coherence in breast ultrasound tomography: a study with a toroidal array. Med Phys. 2009;36:2955–2965
  74. Hirose M, Otsuki N, Hayano D, et al. Multi-volume fusion imaging of MR ductography and MR mammography for patients with nipple discharge. Magn Reson Med Sci. 2006;5:105–112
  75. Voogd AC, Nielsen M, Peterse JL, et al. Differences in risk factors for local and distant recurrence after breast-conserving therapy or mastectomy for stage I and II breast cancer: pooled results of two large European randomized trials. J Clin Oncol. 2001;19:1688–1697
  76. Antonini N, Jones H, Horiot JC, et al. Effect of age and radiation dose on local control after breast conserving treatment: EORTC trial 22881-10882. Radiother Oncol. 2007;82:265–271
  77. Vaidya JS, Tobias JS, Baum M, et al. TARGeted Intraoperative radiotherapy (TARGIT): an innovative approach to partial-breast irradiation. Semin Radiat Oncol. 2005;15:84–91
  78. Goldstein NS, Kestin LJ, Vicini FA. Monomorphic epithelial proliferations: characterization and evidence suggesting they are the pool of partially transformed lesions from which some invasive carcinomas arise. Am J Clin Pathol. 2007;128:1023–1034
  79. Lakhani SR, Chaggar R, Davies S, et al. Genetic alterations in ‘normal’ luminal and myoepithelial cells of the breast. J Pathol. 1999;189:496–503
  80. Li Z, Moore DH, Meng ZH, Ljung BM, Gray JW, Dairkee SH. Increased risk of local recurrence is associated with allelic loss in normal lobules of breast cancer patients. Cancer Res. 2002;62:1000–1003
  81. Belletti B, Vaidya JS, D’Andrea S, et al. Targeted intraoperative radiotherapy impairs the stimulation of breast cancer cell proliferation and invasion caused by surgical wounding. Clin Cancer Res. 2008;14:1325–1332
  82. van Herk M, Remeijer P, Rasch C, Lebesque JV. The probability of correct target dosage: dose-population histograms for deriving treatment margins in radiotherapy. Int J Radiat Oncol Biol Phys. 2000;47:1121–1135
  83. Lirette A, Pouliot J, Aubin M, Larochelle M. The role of electronic portal imaging in tangential breast irradiation: a prospective study. Radiother Oncol. 1995;37:241–245
  84. van Tienhoven G, Lanson JH, Crabeels D, Heukelom S, Mijnheer BJ. Accuracy in tangential breast treatment set-up: a portal imaging study. Radiother Oncol. 1991;22:317–322
  85. Carter DL, Marks LB, Bentel GC. Impact of setup variability on incidental lung irradiation during tangential breast treatment. Int J Radiat Oncol Biol Phys. 1997;38:109–115
  86. Pouliot J, Lirette A. Verification and correction of setup deviations in tangential breast irradiation using EPID: gain versus workload. Med Phys. 1996;23:1393–1398
  87. Valdagni R, Italia C. Early breast cancer irradiation after conservative surgery: quality control by portal localization films. Radiother Oncol. 1991;22:311–313
  88. Creutzberg CL, Althof VG, Huizenga H, Visser AG, Levendag PC. Quality assurance using portal imaging: the accuracy of patient positioning in irradiation of breast cancer. Int J Radiat Oncol Biol Phys. 1993;25:529–539
  89. Mitine C, Dutreix A, Van der Schueren E. Tangential breast irradiation: influence of technique of set-up on transfer errors and reproducibility. Radiother Oncol. 1991;22:308–310
  90. Thilmann C, Adamietz IA, Saran F, Mose S, Kostka A, Bottcher HD. The use of a standardized positioning support cushion during daily routine of breast irradiation. Int J Radiat Oncol Biol Phys. 1998;41:459–463
  91. Hurkmans CW, Remeijer P, Lebesque JV, Mijnheer BJ. Set-up verification using portal imaging; review of current clinical practice. Radiother Oncol. 2001;58:105–120
  92. Hector CL, Evans PM, Webb S. The dosimetric consequences of inter-fractional patient movement on three classes of intensity-modulated delivery techniques in breast radiotherapy. Radiother Oncol. 2001;59:281–291
  93. Hector CL, Webb S, Evans PM. The dosimetric consequences of inter-fractional patient movement on conventional and intensity-modulated breast radiotherapy treatments. Radiother Oncol. 2000;54:57–64
  94. Kinoshita R, Shimizu S, Taguchi H, et al. Three-dimensional intrafractional motion of breast during tangential breast irradiation monitored with high-sampling frequency using a real-time tumor-tracking radiotherapy system. Int J Radiat Oncol Biol Phys. 2008;70:931–934
  95. Hasan Y, Kim L, Martinez A, Vicini F, Yan D. Image guidance in external beam accelerated partial breast irradiation: comparison of surrogates for the lumpectomy cavity. Int J Radiat Oncol Biol Phys. 2007;70:619–625
  96. Baglan KL, Sharpe MB, Jaffray D, et al. Accelerated partial breast irradiation using 3D conformal radiation therapy (3D-CRT). Int J Radiat Oncol Biol Phys. 2003;55:302–311
  97. Hasan Y, Kim L, Wloch J, Chi Y, Liang J, Kestin L, et al. Comparison of planned versus actual dose delivered for external beam accelerated partial breast irradiation (EB ABPI) using cone-beam CT (CBCT) and deformable registration. Int J Radiat Oncol Biol Phys. 2006;S215
  98. Fatunase T, Wang Z, Yoo S, et al. Assessment of the residual error in soft tissue setup in patients undergoing partial breast irradiation: results of a prospective study using cone-beam computed tomography. Int J Radiat Oncol Biol Phys. 2008;70:1025–1034
  99. Beckham W, Salter R, Olivotto I, Kader H, Popescu C, Patenuade V, et al. Changes to CTV margins significantly impact critical organ dosimetry during 3D-external beam conformal partial breast radiotherapy (3D-PBRT). Int J Radiat Oncol Biol Phys. 2005;63(2):A2006
  100. Cox BW, Horst KC, Thornton S, Dirbas FM. Impact of increasing margin around the lumpectomy cavity to define the planning target volume for 3D conformal external beam accelerated partial breast irradiation. Med Dosim. 2007;32:254–262
  101. White EA, Cho J, Vallis KA, et al. Cone beam computed tomography guidance for setup of patients receiving accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys. 2007;68:547–554
  102. Coles C, Donovan E, Harris E, Poynter A, Twyman N, Routsis D, et al. On behalf of the IMPORT Working Party. The IMPORT gold seed study: evaluation of tumour bed localisation and image-guided radiotherapy for breast cancer. Clin Oncol (R Coll Radiol). 2007;19:S26–S27
  103. BIR Working Party. Geometric uncertainties in radiotherapy: defining the planning target volume; 2003.
  104. Struikmans H, Warlam-Rodenhuis C, Stam T, et al. Interobserver variability of clinical target volume delineation of glandular breast tissue and of boost volume in tangential breast irradiation. Radiother Oncol. 2005;76:293–299
  105. Petersen RP, Truong PT, Kader HA, et al. Target volume delineation for partial breast radiotherapy planning: clinical characteristics associated with low interobserver concordance. Int J Radiat Oncol Biol Phys. 2007;69:41–48
  106. Wong EK, Truong PT, Kader HA, et al. Consistency in seroma contouring for partial breast radiotherapy: impact of guidelines. Int J Radiat Oncol Biol Phys. 2006;66:372–376

PII: S0167-8140(09)00668-9

doi: 10.1016/j.radonc.2009.12.010

Radiotherapy & Oncology
Volume 94, Issue 3 , Pages 255-263 , March 2010