Split-VMAT technique to control the deep inspiration breath hold time for breast cancer radiotherapy

Background To improve split-VMAT technique by optimizing treatment delivery time for deep-inspiration breath hold (DIBH) radiotherapy in left-sided breast cancer patients, when automatic beam-interruption devices are not available. Methods Ten consecutive patients were treated with an eight partial arcs (8paVMAT) plan, standard of care in our center. A four partial arcs (4paVMAT) plan was also created and actual LINAC outputs were measured, to evaluate whether there was a dosimetric difference between both techniques and potential impact on the delivered dose. Subsequently, ten other patients were consecutively treated with a 4paVMAT plan to compare the actual treatment delivery time between both techniques. The prescribed dose was 40.05 Gy/15 fractions on the PTV breast (breast or thoracic wall), lymph nodes (LN) and intramammary lymph node chain (IMN). Treatment delivery time, PTVs coverage, conformity index (CI), organs at risk (OAR) dose, monitor units (MU), and gamma index were compared. Results Both split-VMAT techniques resulted in similar dose coverage for the PTV Breast and LN, and similar CI. For PTV IMN we observed a 5% increased coverage for the volume receiving ≥ 36 Gy with 4paVMAT, with an identical volume receiving ≥ 32 Gy. There was no difference for the OAR sparing, with the exception of the contralateral organs: there was a 0.6 Gy decrease for contralateral breast mean (p ≤ 0.01) and 1% decrease for the volume of right lung receiving ≥ 5 Gy (p = 0.024). Overall, these results indicate a modest clinical benefit of using 4paVMAT in comparison to 8paVMAT. An increase in the number of MU per arc was observed for the 4paVMAT technique, as expected, while the total number of MU remained comparable for both techniques. All the plans were measured with the Delta4 phantom and passed the gamma index criteria with no significant differences. Finally, the main difference was seen for the treatment delivery time: there was a significant decrease from 8.9 to 5.4 min for the 4paVMAT plans (p < .05). Conclusions This study is mainly of interest for centers who are implementing the DIBH technique without automatic beam-holding devices and who therefore may require to manually switch the beam on and off during breast DIBH treatment. Split-VMAT technique with 4 partial arcs significantly reduces the treatment delivery time compared to 8 partial arcs, without compromising the target coverage and the OAR sparing. The technique decreases the number of breath holds per fraction, resulting in a shorter treatment session.

Inflammatory Myofibroblastic Tumor of the Breast: A Case Report

Inflammatory myofibroblastic tumors (IMTs) of the breast are extremely uncommon lesions, usually labelled as a subgroup of inflammatory pseudotumors. They are composed of inflammatory cells and bland spindle cells without nuclear atypia. Nearly half of all IMTs of the breast include clonal translocation of the anaplastic lymphoma kinase (ALK) gene, located at the chromosome band 2p23, and generally present with a palpable lump, swelling, and pain. Herein, we present a 66-year-old female patient with pain, swelling and a palpable lump in her right breast. A 40×26 mm sized T1A hypointense and T2A hyperintense mass with slightly lobulated margins was detected at breast magnetic resonance imaging. A mass associated with an intramammary lymph node was evaluated in the upper inner quadrant of the right breast via mammography. The results were considered as BI-RADS 3. Breast-conserving surgery with sentinel lymph node biopsy was performed. During pathological evaluation, cytoplasm with poorly-defined margins, and large-nucleoli tumor cells with benign ducts between these tumor cells, were observed. Intensive inflammatory cell infiltration and sclerotic changes in different areas were also noted. The lesion stained positive for caldesmon, smooth muscle actin, vimentin, CD10, and S100; however, it was negative for ALK on immunohistochemistry. The patient remained disease-free after the surgical procedure.International Journal of Human and Health Sciences Vol. 04 No. 04 October’20 Page : 305-308

Silicone Induced Granuloma of Breast Implant Capsule (SIGBIC) diagnosis: Breast Magnetic Resonance (BMR) ability to detect silicone bleeding

ABSTRACTObjectiveTo evaluate the ability of BMRI to detect silicone gel bleeding in a prospective observational study including consecutive patients referred for BMRI scan. Methods: From January 2017 to March 2018, patients referred for BMRI were evaluated in a prospective observational study. Patients who had breast implants were included. BMRI recorded 9 findings according to BI-RADS lexicon and SIGBIC findings, considered equivocal features to detect gel bleeding (GB). Three new original imaging features were added for SIGBIC diagnosis: black drop signal; T2* hypersignal mass; and delayed contrast enhancement, considered as irrevocable signs. The presence of silicone corpuscle was confirmed by percutaneous biopsy or surgical capsulectomy. Accuracy of BMRI SIGBIC findings to predict GB was determined. We also used univariate analysis for the equivocal features for GB diagnosis. The Backward method was applied for a multivariate Logistic Regression model for the equivocal features. Results: SIGBIC was diagnosed in 208 patients and GB was histologically confirmed in all cases. No false positive results were observed. The most important imaging equivocal feature associated with GB was capsular contracture. In order of prevalence, the main equivocal BMRI features associated to GB with statistically significance (P < =0.001) were as follows: 1.water droplets (OR=2.8; 95%CI 1.8-4.4); 2.enlarged intramammary lymph node (OR=3.1; 95%CI 1.5-6.1); 3.pericapsular edema (OR=5.0; 95%CI 2.3-11.1); and 4.intracapsular seroma (OR=2.4; 95%CI 1.4-4.1).ConclusionSIGBIC diagnosis has high sensitivity to predict GB by the 3 irrevocable BMRI features described by the authors. We suppose GB is underdiagnosed in clinical practice by BI-RADS features.

Cavernous hemangioma: A rare tumor in the breast region

Introduction: Hemangiomas are benign vascular tumors rarely located in the breast (incidence of 0.4% to 0.8%). They mainly affect post-menopause women on hormone replacement therapy (HRT). These tumors are classified as capillary or cavernous according to the size of vessels involved and can show heterogeneity in imaging tests. Case report: The patient is a woman aged 56 years, G3P3, living in the city of Florianópolis. She has been on HRT, without a family history of gynecological cancer. She reported breast implant and bariatric surgery in 2007. The patient sought medical care due to a tumor in the left breast that she noticed six months before, with slight growth. Physical examination identified a superficial purplish nodule in the left axillary tail, measuring 1.5 cm. Magnetic resonance imaging (MRI) revealed an intramammary lymph node (BI-RADS 2); mammography (MMG) indicated a 2.4 cm nodule in the left axillary tail (BI-RADS 4), suggesting biopsy; ultrasound (US) identified an irregular peripheral nodule at 2 h on the left, with the same classification. Core biopsy revealed cavernous hemangioma. Mammaplasty was performed with excision of the lesion. Commentaries: In hemangiomas, imaging findings can vary. MMG usually shows an oval or lobular mass, isodense or high-density, and circumscribed margins. The heterogeneity in the US may be related to vascular channels histologically seen in cavernous hemangiomas. MRI characteristics vary according to the possibility of internal thrombosis, but they often include an ovoid mass and circumscribed margins. The MRI report showed no hemangioma; however, MMG and US indicated similar characteristics. Although rare and with a heterogeneous presentation, hemangioma should be remembered as a differential diagnosis since, in addition to its similarities to benign lesions, such as bruises and sebaceous cysts, it can also be mistaken for inflammatory carcinoma and ductal carcinoma in situ, mimics that have been described in the literature.