Publications by authors named "Carine Kirkove"

18 Publications

  • Page 1 of 1

Unintended dose to the lower axilla in adjuvant radiotherapy for breast cancer: Differences between tangential beam and VMAT.

Radiother Oncol 2021 11 11;164:282-288. Epub 2021 Oct 11.

Department of Radiation Oncology, Breast Working Group, Institut Jules Bordet, Université libre de Bruxelles, Brussels, Belgium. Electronic address:

Background And Purpose: To evaluate dosimetric differences in unintended dose to the lower axilla between 3D-standard (3DCRT), tangential beam forward intensity modulated radiotherapy (F-IMRT) and volumetric modulated arc therapy (VMAT). The objective is to evaluate whether results of clinical trials, such as the ACOSOG-Z011 trial, that evaluated omission of axillary clearance can be extrapolated towards more conformal techniques like VMAT.

Materials And Methods: Twenty-five consecutive patients treated with whole breast radiotherapy alone (WBRT) using a F-IMRT technique were identified. Three additional plans were created for every patient: one plan using a single 270° arc (VMAT 1x270°), another using two small ≤90° opposing arcs (VMAT 2x < 90°) and thirdly a 3DCRT plan without F-IMRT. Axillary levels I-II were contoured after the treatment plans were made.

Results: The volume of the axilla level I that was covered by the 50% isodose (V50%) was significantly higher for VMAT 2x < 90° (71.3 cm, 84% of structure volume, p < 0.001) and VMAT 1x270° (68.8 cm, 81%, p < 0.01) compared to 3DCRT (60.3 cm, 71%) and F-IMRT (60.8 cm, 72%). The V50% to the axilla level II, however, was low for all techniques: 12.3 cm (12%); 8.9 cm (9%); 4.3 cm (4%); 4.4 cm (4%) for VMAT 2x < 90°, VMAT 1x270°, 3DCRT, F-IMRT, respectively. For the higher doses (V90% and above), no clinically relevant differences were seen between the different modalities.

Conclusion: WBRT treatments with VMAT do not lead to a significant reduction of the unintended axillary dose in comparison with a tangential beam setup. Hence, concerning tumor control, VMAT can be applied to clinical situations similar to the Z0011 trial. The intermediate axillary dose is higher with VMAT, but the clinical consequence of this difference on toxicity is unknown.
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http://dx.doi.org/10.1016/j.radonc.2021.10.005DOI Listing
November 2021

Side Effects 15 Years After Lymph Node Irradiation in Breast Cancer: Randomized EORTC Trial 22922/10925.

J Natl Cancer Inst 2021 Oct;113(10):1360-1368

Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.

Background: Uncertainty about the benefit-risk ratio of regional lymph node irradiation led to varying clinical protocols. We investigated long-term late side effects after internal mammary and medial supraclavicular (IM-MS) lymph node irradiation to improve shared decision making.

Methods: The multicenter European Organization for Research and Treatment of Cancer trial (ClinicalTrials.gov, NCT00002851) randomly assigned stage I-III breast cancer patients with involved axillary nodes and/or a medially located primary tumor. We analyzed late side effects both longitudinally at every follow-up and cross-sectionally at 5-year intervals. All statistical tests were 2-sided.

Results: Between 1996 and 2004, 46 departments from 13 countries accrued 4004 patients. Median follow-up was 15.7 years. Longitudinal follow-up data showed cumulative incidence rates at 15 years of 2.9% (95% confidence interval [CI] = 2.2% to 3.8%) vs 5.7% (95% CI = 4.7% to 6.9%) (P < .001) for lung fibrosis, 1.1% (95% CI = 0.7% to 1.7%) vs 1.9% (95% CI = 1.3% to 2.6%) (P = .07) for cardiac fibrosis, and 9.4% (95% CI = 8.0% to 10.8%) vs 11.1% (95% CI = 9.6% to 12.7%) (P = .04) for any cardiac disease when treated without or with IM-MS lymph node irradiation. There was no evidence for differences between left- and right-sided breast cancer (Wald χ2 test of treatment by breast side interaction, P = .33 and P = .35, for cardiac fibrosis and for any cardiac disease, respectively). The cumulative incidence probabilities of cross-sectionally reported side effects with a score of 2 or greater at 15 years were 0.1% (95% CI = 0.0% to 0.5%) vs 0.8% (95% CI = 0.4% to 1.4%) for pulmonary (P = .02), 1.8% (95% CI = 1.1% to 2.8%) vs 2.6% (95% CI = 1.8% to 3.7%) for cardiac (P = .15), and 0.0% (95% CI not evaluated) vs 0.1% (95% CI = 0.0% to 0.4%) for esophageal (P = .16), respectively. No difference was observed in the incidence of second malignancies, contralateral breast cancer, or cardiovascular deaths.

Conclusions: The incidence of late pulmonary side effects was statistically significantly higher after IM-MS lymph node irradiation, as were some of the cardiac events, without a difference between left- and right-sided treatments. Absolute rates and differences were very low, without increased non-breast cancer-related mortality, even before introducing heart-sparing techniques.
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http://dx.doi.org/10.1093/jnci/djab113DOI Listing
October 2021

Indications for individual internal mammary node irradiation - Authors' reply.

Lancet Oncol 2021 02;22(2):e41

Department of Radiation Oncology, University Hospital Saint Luc, Université Catholique de Louvain, Brussels, Belgium.

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http://dx.doi.org/10.1016/S1470-2045(21)00026-7DOI Listing
February 2021

Internal mammary and medial supraclavicular lymph node chain irradiation in stage I-III breast cancer (EORTC 22922/10925): 15-year results of a randomised, phase 3 trial.

Lancet Oncol 2020 12 2;21(12):1602-1610. Epub 2020 Nov 2.

Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands.

Background: 10-year results from several studies showed improved disease-free survival and distant metastasis-free survival, reduced breast cancer-related mortality, and variable effects on overall survival with the addition of partial or comprehensive regional lymph node irradiation after surgery in patients with breast cancer. We present the scheduled 15-year analysis of the European Organisation for Research and Treatment of Cancer (EORTC) 22922/10925 trial, which aims to investigate the impact on overall survival of elective internal mammary and medial supraclavicular (IM-MS) irradiation.

Methods: EORTC 22922/10925, a randomised, phase 3 trial done across 46 radiation oncology departments from 13 countries, included women up to 75 years of age with unilateral, histologically confirmed, stage I-III breast adenocarcinoma with involved axillary nodes or a central or medially located primary tumour. Surgery consisted of mastectomy or breast-conserving surgery and axillary staging. Patients were randomly assigned (1:1) centrally using minimisation to receive IM-MS irradiation at 50 Gy in 25 fractions (IM-MS irradiation group) or no IM-MS irradiation (control group). Stratification was done for institution, menopausal status, site of the primary tumour within the breast, type of breast and axillary surgery, and pathological T and N stage. Patients and investigators were not masked to treatment allocation. The primary endpoint was overall survival analysed according to the intention-to-treat principle. Secondary endpoints were disease-free survival, distant metastasis-free survival, breast cancer mortality, any breast cancer recurrence, and cause of death. Follow-up is ongoing for 20 years after randomisation. This study is registered with ClinicalTrials.gov, NCT00002851.

Findings: Between Aug 5, 1996, and Jan 13, 2004, we enrolled 4004 patients, of whom 2002 were randomly assigned to the IM-MS irradiation group and 2002 to the no IM-MS irradiation group. At a median follow-up of 15·7 years (IQR 14·0-17·6), 554 (27·7%) patients in the IM-MS irradiation group and 569 (28·4%) patients in the control group had died. Overall survival was 73·1% (95% CI 71·0-75·2) in the IM-MS irradiation group and 70·9% (68·6-72·9) in the control group (HR 0·95 [95% CI 0·84-1·06], p=0·36). Any breast cancer recurrence (24·5% [95% CI 22·5-26·6] vs 27·1% [25·1-29·2]; HR 0·87 [95% CI 0·77-0·98], p=0·024) and breast cancer mortality (16·0% [14·3-17·7] vs 19·8% [18·0-21·7]; 0·81 [0·70-0·94], p=0·0055) were lower in the IM-MS irradiation group than in the control group. No significant differences in the IM-MS irradiation group versus the control group were seen for disease-free survival (60·8% [95% CI 58·4-63·2] vs 59·9% [57·5-62·2]; HR 0·93 [95% CI 0·84-1·03], p=0·18), or distant metastasis-free survival (70·0% [67·7-72·2] vs 68·2% [65·9-70·3]; 0·93 [0·83-1·04], p=0·18). Causes of death between groups were similar.

Interpretation: The 15-year results show a significant reduction of breast cancer mortality and any breast cancer recurrence by IM-MS irradiation in stage I-III breast cancer. However, this is not converted to improved overall survival.

Funding: US National Cancer Institute, Ligue Nationale contre le Cancer, and KWF Kankerbestrijding.
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http://dx.doi.org/10.1016/S1470-2045(20)30472-1DOI Listing
December 2020

International comparison of cosmetic outcomes of breast conserving surgery and radiation therapy for women with ductal carcinoma in situ of the breast.

Radiother Oncol 2020 01 17;142:180-185. Epub 2019 Aug 17.

University of New South Wales (NSW), Sydney, Australia.

Purpose: To assess the cosmetic impact of breast conserving surgery (BCS), whole breast irradiation (WBI) fractionation and tumour bed boost (TBB) use in a phase III trial for women with ductal carcinoma in situ (DCIS) of the breast.

Materials And Methods: Baseline and 3-year cosmesis were assessed using the European Organization for Research and Treatment of Cancer (EORTC) Cosmetic Rating System and digital images in a randomised trial of non-low risk DCIS treated with postoperative WBI +/- TBB. Baseline cosmesis was assessed for four geographic clusters of treating centres. Cosmetic failure was a global score of fair or poor. Cosmetic deterioration was a score change from excellent or good at baseline to fair or poor at three years. Odds ratios for cosmetic deterioration by WBI dose-fractionation and TBB use were calculated for both scoring systems.

Results: 1608 women were enrolled from 11 countries between 2007 and 2014. 85-90% had excellent or good baseline cosmesis independent of geography or assessment method. TBB (16 Gy in 8 fractions) was associated with a >2-fold risk of cosmetic deterioration (p < 0.001). Hypofractionated WBI (42.5 Gy in 16 fractions) achieved statistically similar 3-year cosmesis compared to conventional WBI (50 Gy in 25 fractions) (p ≥ 0.18). The adverse impact of a TBB was not significantly associated with WBI fractionation (interaction p ≥ 0.30).

Conclusions: Cosmetic failure from BCS was similar across international jurisdictions. A TBB of 16 Gy increased the rate of cosmetic deterioration. Hypofractionated WBI achieved similar 3-year cosmesis as conventional WBI in women treated with BCS for DCIS.
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http://dx.doi.org/10.1016/j.radonc.2019.07.024DOI Listing
January 2020

ESTRO ACROP consensus guideline for target volume delineation in the setting of postmastectomy radiation therapy after implant-based immediate reconstruction for early stage breast cancer.

Radiother Oncol 2019 08 17;137:159-166. Epub 2019 May 17.

Department of Radiation Oncology, Institut Curie, and Paris Sciences & Lettres University, Paris, France.

Immediate breast reconstruction (IBR) rates after mastectomy are increasing. Postmastectomy radiation therapy (PMRT) contouring guidelines for target volumes in the setting of IBR are lacking. Therefore, many patients who have had IBR receive PMRT to target volumes similar to conventional simulator-based whole breast irradiation. The aim of this paper is to describe delineation guidelines for PMRT after implant-based IBR based on a thorough understanding of the surgical procedures, disease stage, patterns of recurrence and radiation techniques. They are based on a consensus endorsed by a global multidisciplinary group of breast cancer experts.
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http://dx.doi.org/10.1016/j.radonc.2019.04.010DOI Listing
August 2019

Outcome and prognostic factors in 110 consecutive patients with primary uterine leiomyosarcoma: A Rare Cancer Network study.

Chin J Cancer Res 2017 Dec;29(6):521-532

Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland.

Objective: Primary uterine leiomyosarcomas (ULMS) are rare, and the optimal treatment is controversial. We aimed to assess the outcome and prognostic factors in a multicenter population of women treated for primary ULMS.

Methods: We retrospectively collected data of 110 women treated in 19 institutions of the Rare Cancer Network (RCN). Inclusion criteria consisted of a pathology report confirming the diagnosis of ULMS, aged 18-80 years, complete International Federation of Gynecology and Obstetrics (FIGO) stage information, complete information on treatment, and a minimum follow-up of 6 months. Local control (LC) and locoregional control (LRC), overall survival (OS) and disease-free survival (DFS) rates were computed using the Kaplan-Meier method. Univariate analysis was implemented using the log rank test, and multivariate analysis using the Cox model.

Results: All patients underwent surgery. Seventy-five patients (68%) received adjuvant radiotherapy (RT), including brachytherapy in 18 (16%). Seventeen patients (15%) received adjuvant chemotherapy. Median follow-up was 58 (range, 6-240) months. Five-year OS and DFS rates were 50% and 34%, and LC and LRC rates were 88% and 72%, respectively. On multivariate analysis, independent favorable prognostic factors were younger age, FIGO stage I, small tumor size, previous uterine disease, and no vascular invasion for OS and DFS. FIGO stage was the only favorable factor influencing LRC. Adjuvant local or systemic treatments did not improve the outcomes. Eight patients treated with RT presented a grade 3 acute toxicity, and only one patient with grade 3 late toxicity.

Conclusions: In this large population of primary ULMS patients, we found good results in terms of LC and LRC. Nevertheless, OS remains poor, mainly due to the occurrence of distant metastases. An early diagnosis seemed to improve the prognosis of the patients. Adjuvant local or systemic treatments, or more aggressive surgical procedures such as the Wertheim procedure, did not seem to impact the outcome.
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http://dx.doi.org/10.21147/j.issn.1000-9604.2017.06.06DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5775016PMC
December 2017

Quality assessment of delineation and dose planning of early breast cancer patients included in the randomized Skagen Trial 1.

Radiother Oncol 2017 05 25;123(2):282-287. Epub 2017 Mar 25.

Department of Oncology, Aarhus University Hospital, Denmark. Electronic address:

Background And Purpose: To report on a Quality assessment (QA) of Skagen Trial 1, exploring hypofractionation for breast cancer patients with indication for regional nodal radiotherapy.

Material And Methods: Deviations from protocol regarding target volume delineations and dose parameters (Dmin, Dmax, D98%, D95% and D2%) from randomly selected dose plans were assessed. Target volume delineation according to ESTRO guidelines was obtained through atlas based automated segmentation and centrally approved as gold standard (GS). Dice similarity scores (DSC) with original delineations were measured. Dose parameters measured in the two delineations were reported to assess their dosimetric outcome.

Results: Assessment included 88 plans from 12 centres in 4 countries. DSC showed high agreement in contouring, 99% and 96% of the patients had a complete delineation of target volumes and organs at risk. No deviations in the dosimetric outcome were found in 76% of the patients, 82% and 95% of the patients had successful coverage of breast/chestwall and CTVn_L2-4-interpectoral. Dosimetric outcomes of original delineation and GS were comparable.

Conclusions: QA showed high protocol compliance and adequate dose coverage in most patients. Inter-observer variability in contouring was low. Dose parameters were in harmony with protocol regardless original or GS segmentation.
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http://dx.doi.org/10.1016/j.radonc.2017.03.011DOI Listing
May 2017

Dosimetric assessment of an Atlas based automated segmentation for loco-regional radiation therapy of early breast cancer in the Skagen Trial 1: A multi-institutional study.

Clin Transl Radiat Oncol 2017 Feb 6;2:36-40. Epub 2017 Feb 6.

Department of Oncology, Aarhus University Hospital, Norrebrogade 44, DK-8000 Aarhus C, Denmark.

The effect of Atlas-based automated segmentation (ABAS) on dose volume histogram (DVH) parameters compared to manual segmentation (MS) in loco-regional radiotherapy (RT) of early breast cancer was investigated in patients included in the Skagen Trial 1. This analysis supports implementation of ABAS in clinical practice and multi-institutional trials.
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http://dx.doi.org/10.1016/j.ctro.2017.01.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5893527PMC
February 2017

Internal and external validation of an ESTRO delineation guideline - dependent automated segmentation tool for loco-regional radiation therapy of early breast cancer.

Radiother Oncol 2016 12 30;121(3):424-430. Epub 2016 Sep 30.

Department of Oncology, Aarhus University Hospital, Denmark. Electronic address:

Background And Purpose: To internally and externally validate an atlas based automated segmentation (ABAS) in loco-regional radiation therapy of breast cancer.

Materials And Methods: Structures of 60 patients delineated according to the ESTRO consensus guideline were included in four categorized multi-atlas libraries using MIM Maestro™ software. These libraries were used for auto-segmentation in two different patient groups (50 patients from the local institution and 40 patients from other institutions). Dice Similarity Coefficient, Average Hausdorff Distance, difference in volume and time were computed to compare ABAS before and after correction against a gold standard manual segmentation (MS).

Results: ABAS reduced the time of MS before and after correction by 93% and 32%, respectively. ABAS showed high agreement for lung, heart, breast and humeral head, moderate agreement for chest wall and axillary nodal levels and poor agreement for interpectoral, internal mammary nodal regions and LADCA. Correcting ABAS significantly improved all the results. External validation of ABAS showed comparable results.

Conclusions: ABAS is a clinically useful tool for segmenting structures in breast cancer loco-regional radiation therapy in a multi-institutional setting. However, manual correction of some structures is important before clinical use. The ABAS is now available for routine clinical use in Danish patients.
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http://dx.doi.org/10.1016/j.radonc.2016.09.005DOI Listing
December 2016

Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer.

N Engl J Med 2015 Jul;373(4):317-27

From the Department of Radiation Oncology, Radboud University Medical Center, Nijmegen (P.M.P.), Department of Radiation Oncology, Institute Verbeeten, Tilburg (P.M.P., K.D.W.), Department of Radiation Oncology, Medisch Centrum Haaglanden, The Hague (H.S.), Department of Radiation Oncology, University Medical Center Utrecht, Utrecht (H.S., C.R.), Department of Radiation Oncology, Institute for Radiation Oncology Radiotherapeutisch Instituut Stedendriehoek en Omstreken, Deventer (E.V.), Department of Radiation Oncology, Academic Medical Center (G.T.), and Department of Radiation Oncology, the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital (H.B.), Amsterdam - all in the Netherlands; European Organization for Research and Treatment of Cancer (EORTC) Headquarters (S.C., L.C.) and Department of Radiation Oncology, University Hospital Saint-Luc, Université Catholique de Louvain (C.K.), Brussels, and Department of Radiation Oncology, University Hospital Gasthuisberg, Leuven (E.V.L., W.V.B.) - all in Belgium; Department of Radiation Oncology, Charité University Medicine Berlin, Berlin (V.B., S.M.), and Department of Radiation Oncology, University Hospital, Tübingen (N.W.) - both in Germany; Department of Radiation Oncology, Institut Curie, Paris (A.F.), Department of Radiation Oncology, Centre Georges-François Leclerc, Dijon (P.M., I.B.), Department of Radiation Oncology, Université François Rabelais, Tours (I.B.), and Department of Radiation Oncology, Gustave Roussy Cancer Center, Villejuif (H.M.) - all in France; Department of Radiation Oncology, Ospedale Regionale di Bellinzona e Valli, Bellinzona (M.V.), and Department of Radiation Oncology, University Hospital Zurich (C.G.) - both in Switzerland; Department of Radiation Oncology, Sant'Anna Hospital, Como, Italy (M.V., L.S.); Department of Radiation Oncology, Rambam Medical Center, Haifa, Israel (A.K.); and Grupo Oncológico Cooperativo Chileno de Investigación, Santiago, Chile (R.A.).

Background: The effect of internal mammary and medial supraclavicular lymph-node irradiation (regional nodal irradiation) added to whole-breast or thoracic-wall irradiation after surgery on survival among women with early-stage breast cancer is unknown.

Methods: We randomly assigned women who had a centrally or medially located primary tumor, irrespective of axillary involvement, or an externally located tumor with axillary involvement to undergo either whole-breast or thoracic-wall irradiation in addition to regional nodal irradiation (nodal-irradiation group) or whole-breast or thoracic-wall irradiation alone (control group). The primary end point was overall survival. Secondary end points were the rates of disease-free survival, survival free from distant disease, and death from breast cancer.

Results: Between 1996 and 2004, a total of 4004 patients underwent randomization. The majority of patients (76.1%) underwent breast-conserving surgery. After mastectomy, 73.4% of the patients in both groups underwent chest-wall irradiation. Nearly all patients with node-positive disease (99.0%) and 66.3% of patients with node-negative disease received adjuvant systemic treatment. At a median follow-up of 10.9 years, 811 patients had died. At 10 years, overall survival was 82.3% in the nodal-irradiation group and 80.7% in the control group (hazard ratio for death with nodal irradiation, 0.87; 95% confidence interval [CI], 0.76 to 1.00; P=0.06). The rate of disease-free survival was 72.1% in the nodal-irradiation group and 69.1% in the control group (hazard ratio for disease progression or death, 0.89; 95% CI, 0.80 to 1.00; P=0.04), the rate of distant disease-free survival was 78.0% versus 75.0% (hazard ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02), and breast-cancer mortality was 12.5% versus 14.4% (hazard ratio, 0.82; 95% CI, 0.70 to 0.97; P=0.02). Acute side effects of regional nodal irradiation were modest.

Conclusions: In patients with early-stage breast cancer, irradiation of the regional nodes had a marginal effect on overall survival. Disease-free survival and distant disease-free survival were improved, and breast-cancer mortality was reduced. (Funded by Fonds Cancer; ClinicalTrials.gov number, NCT00002851.).
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http://dx.doi.org/10.1056/NEJMoa1415369DOI Listing
July 2015

In Regard to Vaidya et al.

Int J Radiat Oncol Biol Phys 2015 Aug 14;92(5):960-961. Epub 2015 Jul 14.

Department of Radiation Oncology, Gustave Roussy, France.

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http://dx.doi.org/10.1016/j.ijrobp.2015.05.030DOI Listing
August 2015

ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage breast cancer.

Radiother Oncol 2015 Jan 24;114(1):3-10. Epub 2015 Jan 24.

Department of Radiation Oncology, Radboud university medical centre, The Netherlands.

Background And Purpose: Delineation of clinical target volumes (CTVs) is a weak link in radiation therapy (RT), and large inter-observer variation is seen in breast cancer patients. Several guidelines have been proposed, but most result in larger CTVs than based on conventional simulator-based RT. The aim was to develop a delineation guideline obtained by consensus between a broad European group of radiation oncologists.

Material And Methods: During ESTRO teaching courses on breast cancer, teachers sought consensus on delineation of CTV through dialogue based on cases. One teacher delineated CTV on CT scans of 2 patients, followed by discussion and adaptation of the delineation. The consensus established between teachers was sent to other teams working in the same field, both locally and on a national level, for their input. This was followed by developing a broad consensus based on discussions.

Results: Borders of the CTV encompassing a 5mm margin around the large veins, running through the regional lymph node levels were agreed, and for the breast/thoracic wall other vessels were pointed out to guide delineation, with comments on margins for patients with advanced breast cancer.

Conclusion: The ESTRO consensus on CTV for elective RT of breast cancer, endorsed by a broad base of the radiation oncology community, is presented to improve consistency.
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http://dx.doi.org/10.1016/j.radonc.2014.11.030DOI Listing
January 2015

Vessel based delineation guidelines for the elective lymph node regions in breast cancer radiation therapy - PROCAB guidelines.

Radiother Oncol 2015 Jan 19;114(1):11-6. Epub 2014 Nov 19.

Catholic University of Louvain, Brussels, Belgium.

Objective: A national project to improve the quality of breast radiation therapy was started, named PROCAB (PROject on CAncer of the Breast). One of the objectives was to reach a national consensus guideline for the delineation of the regional lymph node areas in breast radiation therapy.

Methods: The realization of the new guidelines was a step by step process that started with multiple expert meetings where the existing guidelines were analyzed and the delineations of the lymph node regions were performed together with a surgeon, specialized in the anatomy of the drainage of the breast.

Results: The delineation guidelines are vessel-based. Since the occurrence of pathological lymph nodes is typically around the veins, the cranial and caudal borders of all different nodal regions are based on a 5mm margin around the veins, except for the parasternal lymph node area. Compared to the existing guidelines there are some major changes.

Conclusion: With this project a national as well as a European (ESTRO) consensus guideline for the delineation of the regional lymph node areas in breast RT is reached. The new delineation atlas is vessel-based and no longer field-based.
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http://dx.doi.org/10.1016/j.radonc.2014.11.008DOI Listing
January 2015

Breast cancer in elderly women: can radiotherapy be omitted?

Eur J Cancer 2007 Oct 20;43(15):2264-9. Epub 2007 Jul 20.

Department Radiation Oncology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, 10, Avenue Hippocrate, UCL 4763, B-1200 Bruxelles, Belgium.

It is tempting to spare elderly women the burden of adjuvant radiotherapy after breast cancer surgery, even if such a treatment would be justified in light of the available clinical evidence. The reason is that evidence-based radiotherapy derives from clinical trials that excluded elderly women, and that breast cancer is often believed to be more indolent at advanced ages. Unfortunately, the epidemiological evidence, and the few clinical trials recruiting patients over 65 or 70 year of age, all point to the need for postoperative irradiation in a similar set-up as in younger patients. So far, there is no evidence that a subgroup exists in which radiotherapy can be safely omitted. Therefore, the decision to treat or not to treat should be openly discussed with the patient, addressing risks and benefits of both attitudes. Only in frail patients, with an obviously limited life expectancy (months or at most a few years), can omission of radiotherapy be considered, as the burden of local recurrence is likely not to appear before the patient dies from an other cause.
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http://dx.doi.org/10.1016/j.ejca.2007.06.003DOI Listing
October 2007

Quality assurance in breast cancer: EORTC experiences in the phase III trial on irradiation of the internal mammary nodes.

Eur J Cancer 2007 Mar 19;43(4):718-24. Epub 2007 Jan 19.

EORTC, Avenue E. Mounierlaan, 83/11, 1200 Brussels, Belgium.

The EORTC 22922/10925 trial randomly compares irradiation or no irradiation of the internal mammary and medio supraclavicular (IM-MS) nodes for stage I-III breast cancer. We report on the characteristics of 4004 participating patients, aspects of quality assurance and compliance to protocol treatment. The actual population has intermediate-risk disease: 51.8% stage II, 56% positive axillary nodes. The allocated treatment was not followed in 3.2% in the IM-MS irradiation arm versus 2% in the no IM-MS irradiation arm. In the IM-MS arm, there were major deviations for dose in 0.8%, surgery-to-radiotherapy time interval in 3.9% and in overall treatment time in 0.9% cases. Major deviations were found in 7.9% patients in the IM-MS group and in 2% patients in the no IM-MS group. In the final trial analysis, a sensitivity analysis should evaluate the subgroup of patients receiving an optimal treatment to verify the robustness of the results and the true impact of IM-MS irradiation.
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http://dx.doi.org/10.1016/j.ejca.2006.11.015DOI Listing
March 2007
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