State of the art in breast intraoperative electron radiation therapy after intraoperative ultrasound introduction

Abstract

Background Breast intraoperative electron radiation therapy (B-IOERT) can be used in clinical practice both as elective irradiation (partial breast irradiation – APBI) in low risk breast cancer patients, and as an anticipated boost. The procedure generally includes the use of a shielding disk between the residual breast and the pectoralis fascia for the protection of the tissues underneath the target volume. The aim of the study was to evaluate the role of intraoperative ultrasound (IOUS) in improving the quality of B-IOERT. Patients and methods B-IOERT was introduced in Trieste in 2012 and its technique was improved in 2014 with IOUS. Both, needle and IOUS were used to measure target thickness and the latter was used even to check the correct position of the shielding disk. The primary endpoint of the study was the evaluation of the effectiveness of IOUS in reducing the risk of a disk misalignment related to B-IOERT and the secondary endpoint was the analysis of acute and late toxicity, by comparing two groups of patients treated with IOERT as a boost, either measured with IOUS and needle (Group 1) or with needle alone (Group 2). Acute and late toxicity were evaluated by validated scoring systems. Results From the institutional patients who were treated between June 2012 and October 2019, 109 were eligible for this study (corresponding to 110 cases, as one patients underwent bilateral conservative surgery and bilateral B-IOERT). Of these, 38 were allocated to group 1 and 72 to group 2. The target thickness measured with the IOUS probe and with the needle were similar (mean difference of 0.1 mm, p = 0.38). The percentage of patients in which the shield was perfectly aligned after IOUS introduction increased from 23% to more than 70%. Moreover, patients treated after IOUS guidance had less acute toxicity (36.8% vs. 48.6%, p = 0.33) from radiation therapy, which reached no statistical significance. Late toxicity turned out to be similar regardless of the use of IOUS guidance: 39.5% vs. 37.5% (p = 0.99). Conclusions IOUS showed to be accurate in measuring the target depth and decrease the misalignment between collimator and disk. Furthermore there was an absolute decrease in acute toxicity, even though not statistically significant, in the group of women who underwent B-IOERT with IOUS guidance.

A systematic review and meta-analysis of intraoperative electron radiation therapy delivered with a dedicated mobile linac for partial breast irradiation in early breast cancer

“…In the future, improved target volume coverage by using real-time imaging and treatment planning during the surgical and IOeRT procedure will facilitate optimal selection and positioning of the linac's applicator and electron energy [ 55 ]. FLASH-irradiation is set to be explored in this field as well, as a possible solution for increasing irradiated volumes without increasing side effects [ 56 ].…”

A Novel Treatment Planning Design for Intraoperative Electron Radiation Therapy (IOERT) using an Electronic Board

“…Figure 5 shows that electrons with higher energy are better in treatment. Due to the different thicknesses of the target tissue, the right energy for treatment [ 37 ] and the irradiation time are managed.…”