This recommendation consensus for hypofractionated whole-breast radiotherapy (RT) was organized by the Brazilian Society of Radiotherapy (SBRT) considering the optimal scenario for indication and safety in the technology applied. All controversies and contraindication matters (hypofractionated RT in patients who underwent chemotherapy [CT], hypofractionated RT in lymphatic drainage, hypofractionated RT after mastectomy with or without immediate reconstruction, boost during surgery, hypofractionated RT in patients under 50 years old, hypofractionated RT in large breasts, hypofractionated RT in histology of carcinoma in situ [DCIS]) was discussed during a meeting in person, and a consensus was reached when there was an agreement of at least 75% among panel members. The grade for recommendation was also suggested according to the level of scientific evidence available, qualified as weak, medium, or strong. Thus, this consensus will aid Brazilian radiotherapy experts regarding indications and particularities of this technique as a viable and safe alternative for the national reality.
GUIDELINES IN FOCUS • Rev. Assoc. Med. Bras. 64
(9)
• Sept 2018 • https://doi.org/10.1590/1806-9282.64.09.770 linkcopy
Recommendations for hypofractionated whole-breast irradiation
Authorship
personSBRT, Brazilian Society of Radiotherapy
person Nilceana Maya Aires Freitas
Participant
school. Radiotherapy Department of the Araújo Jorge Hospital of the Góias State Association Against Cancer, Goiânia/GO, Brasil.Góias State Association Against CancerBrasilGoiânia, GO, Brasil. Radiotherapy Department of the Araújo Jorge Hospital of the Góias State Association Against Cancer, Goiânia/GO, Brasil.
person Arthur Accioly Rosa
Participant
school. Radiotherapy Department of the Bahia State Portuguese Hospital, Salvador/BA and President of the Brazilian Radiotherapy Society (SBRT), São Paulo/SP, Brasil.Bahia State Portuguese HospitalBrazilSalvador, BA, Brazil. Radiotherapy Department of the Bahia State Portuguese Hospital, Salvador/BA and President of the Brazilian Radiotherapy Society (SBRT), São Paulo/SP, Brasil.
person Gustavo Nader Marta
Participant
school. Department of Radiology and Oncology, Division of Radiation Oncology, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.Universidade de São PauloBrazilSão Paulo, Brazil. Department of Radiology and Oncology, Division of Radiation Oncology, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.school. Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.Hospital Sírio-LibanêsBrazilSão Paulo, Brazil. Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.
person Samir Abdalla Hanna
Participant
person Rodrigo de Morais Hanriot
Participant
person Allisson Bruno Barcelos Borges
Participant
person Guilherme Rocha Melo Gondim
Participant
school. Radiotherapy Department of the Oswaldo Cruz German Hospital, São Paulo/SP, Brasil.Oswaldo Cruz German HospitalBrasilSão Paulo, SP, Brasil. Radiotherapy Department of the Oswaldo Cruz German Hospital, São Paulo/SP, Brasil.school. Radiotherapy Department of the AC Camargo Hospital, São Paulo/SP, Brasil.AC Camargo HospitalBrasilSão Paulo, SP, Brasil. Radiotherapy Department of the AC Camargo Hospital, São Paulo/SP, Brasil.
person Antonio Cassio Assis Pellizzon
Participant
person Igor Moreira Veras
Participant
person Wilson José de Almeida Júnior
Participant
person Claudia Regina Scaramello Hadlich Willis Fernandez
Participant
school. Radiotherapy Service of the José Alencar Gomes da Silva National Cancer Institute, Rio de Janeiro/RJ, Brasil.José Alencar Gomes da Silva National Cancer InstituteBrasilRio de Janeiro, RJ, Brasil. Radiotherapy Service of the José Alencar Gomes da Silva National Cancer Institute, Rio de Janeiro/RJ, Brasil.
person Eronides Salustiano Batalha Filho
Participant
school. Radiotherapy Department of the Brasilia State University Hospital and representative of the Ministry of Health, Brasíli/DF, Brasil.Brasilia State University HospitalBrazilBrazil. Radiotherapy Department of the Brasilia State University Hospital and representative of the Ministry of Health, Brasíli/DF, Brasil.
person Marcus Simões Castilho
Participant
person Felipe Quintino Kuhnen
Participant
person Rosa Maria Xavier Faria Najas
Participant
person Renato José Affonso Júnior
Participant
person André Campana Correia Leite
Participant
person Homero Lavieri Martins Ribeiro
Participant
person Ruffo Freitas Junior
Participant
school. Mastology Program of the Goias Federal University, Goiânia-GO and representative of the Brazilian Mastology Society, São Paulo/SP, Brasil.Goias Federal UniversityBrazilGoiânia, GO, Brazil. Mastology Program of the Goias Federal University, Goiânia-GO and representative of the Brazilian Mastology Society, São Paulo/SP, Brasil.
person Harley Francisco de Oliveira
Participant
school. Centro de Tratamento em Radio-Oncologia (CTR) and Ribeirão Preto Medical School (FMRP) da Universidade de São Paulo (USP) - Ribeirão Preto/SP; Hospital Márcio Cunha (HMC) - Ipatinga/MG, Brasil.Universidade de São PauloBrazilRibeirão Preto, SP, Brazil. Centro de Tratamento em Radio-Oncologia (CTR) and Ribeirão Preto Medical School (FMRP) da Universidade de São Paulo (USP) - Ribeirão Preto/SP; Hospital Márcio Cunha (HMC) - Ipatinga/MG, Brasil.schoolHospital Márcio Cunha, Ipatinga, MG, BrasilHospital Márcio CunhaBrasilIpatinga, MG, BrasilHospital Márcio Cunha, Ipatinga, MG, Brasil
CORRESPONDING AUTHOR: Harley Francisco de Oliveira. Brazilian Society of Radiotherapy -SBRT – Pça. Oswaldo Cruz, 124 – cj. 52 – 5
o andar. Paraíso – São Paulo – SP – CEP 04004-070 – Phone/Fax: (11) 3262-3976. E-mail:
sbradioterapia@sbradioterapia.com.br,
sbradioterapia@uol.com.br
o andar. Paraíso – São Paulo – SP – CEP 04004-070 – Phone/Fax: (11) 3262-3976. E-mail:
sbradioterapia@sbradioterapia.com.br,
sbradioterapia@uol.com.br
SCIMAGO INSTITUTIONS RANKINGS
. Radiotherapy Department of the Araújo Jorge Hospital of the Góias State Association Against Cancer, Goiânia/GO, Brasil.Góias State Association Against CancerBrasilGoiânia, GO, Brasil. Radiotherapy Department of the Araújo Jorge Hospital of the Góias State Association Against Cancer, Goiânia/GO, Brasil.
. Radiotherapy Department of the Bahia State Portuguese Hospital, Salvador/BA and President of the Brazilian Radiotherapy Society (SBRT), São Paulo/SP, Brasil.Bahia State Portuguese HospitalBrazilSalvador, BA, Brazil. Radiotherapy Department of the Bahia State Portuguese Hospital, Salvador/BA and President of the Brazilian Radiotherapy Society (SBRT), São Paulo/SP, Brasil.
. Department of Radiology and Oncology, Division of Radiation Oncology, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.Universidade de São PauloBrazilSão Paulo, Brazil. Department of Radiology and Oncology, Division of Radiation Oncology, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
. Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.Hospital Sírio-LibanêsBrazilSão Paulo, Brazil. Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil.
. Radiotherapy Department of the Oswaldo Cruz German Hospital, São Paulo/SP, Brasil.Oswaldo Cruz German HospitalBrasilSão Paulo, SP, Brasil. Radiotherapy Department of the Oswaldo Cruz German Hospital, São Paulo/SP, Brasil.
. Radiotherapy Department, Barretos Cancer Hospital, Barretos/SP, Brasil.Barretos Cancer HospitalBrasilBarretos, SP, Brasil. Radiotherapy Department, Barretos Cancer Hospital, Barretos/SP, Brasil.
. Radiotherapy Department of the AC Camargo Hospital, São Paulo/SP, Brasil.AC Camargo HospitalBrasilSão Paulo, SP, Brasil. Radiotherapy Department of the AC Camargo Hospital, São Paulo/SP, Brasil.
. Radiotherapy Department of the Regional Integrated Oncology Center, Fortaleza-CE.Regional Integrated Oncology CenterBrazilFortaleza, CE, Brazil. Radiotherapy Department of the Regional Integrated Oncology Center, Fortaleza-CE.
. Radiotherapy Department of the Moinhos dos Ventos Hospital, Porto Alegre-RS.Moinhos dos Ventos HospitalBrazilPorto Alegre, RS, Brazil. Radiotherapy Department of the Moinhos dos Ventos Hospital, Porto Alegre-RS.
. Radiotherapy Service of the José Alencar Gomes da Silva National Cancer Institute, Rio de Janeiro/RJ, Brasil.José Alencar Gomes da Silva National Cancer InstituteBrasilRio de Janeiro, RJ, Brasil. Radiotherapy Service of the José Alencar Gomes da Silva National Cancer Institute, Rio de Janeiro/RJ, Brasil.
. Radiotherapy Department of the Brasilia State University Hospital and representative of the Ministry of Health, Brasíli/DF, Brasil.Brasilia State University HospitalBrazilBrazil. Radiotherapy Department of the Brasilia State University Hospital and representative of the Ministry of Health, Brasíli/DF, Brasil.
ministério da saúde, Ministry of Health, Brasíli, DF, BrasilMinistry of HealthBrasilBrasíli, DF, Brasilministério da saúde, Ministry of Health, Brasíli, DF, Brasil
. Radiotherapy Department of the Felicio Rocho Hospital, Belo Horizonte/MG, Brasil.Felicio Rocho HospitalBrasilBelo Horizonte, MG, Brasil. Radiotherapy Department of the Felicio Rocho Hospital, Belo Horizonte/MG, Brasil.
. Radiotherapy Department of the Charity Hospital of Florianópolis, Florianópolis/SC, Brasil.Charity Hospital of FlorianópolisBrasilFlorianópolis, SC, Brasil. Radiotherapy Department of the Charity Hospital of Florianópolis, Florianópolis/SC, Brasil.
. Radiotherapy Department of the Rio Grande do Norte State League Against Cancer, Natal/RN, Brasil.Rio Grande do Norte State League Against CancerBrasilNatal, RN, Brasil. Radiotherapy Department of the Rio Grande do Norte State League Against Cancer, Natal/RN, Brasil.
. Department of Radiation Oncology, Fundação Centro de Controle de Oncologia Manaus- AM.Fundação Centro de Controle de OncologiaBrazilManaus, AM, Brazil. Department of Radiation Oncology, Fundação Centro de Controle de Oncologia Manaus- AM.
. Mastology Program of the Goias Federal University, Goiânia-GO and representative of the Brazilian Mastology Society, São Paulo/SP, Brasil.Goias Federal UniversityBrazilGoiânia, GO, Brazil. Mastology Program of the Goias Federal University, Goiânia-GO and representative of the Brazilian Mastology Society, São Paulo/SP, Brasil.
. Centro de Tratamento em Radio-Oncologia (CTR) and Ribeirão Preto Medical School (FMRP) da Universidade de São Paulo (USP) - Ribeirão Preto/SP; Hospital Márcio Cunha (HMC) - Ipatinga/MG, Brasil.Universidade de São PauloBrazilRibeirão Preto, SP, Brazil. Centro de Tratamento em Radio-Oncologia (CTR) and Ribeirão Preto Medical School (FMRP) da Universidade de São Paulo (USP) - Ribeirão Preto/SP; Hospital Márcio Cunha (HMC) - Ipatinga/MG, Brasil.
Tables
Level of agreement
Level of evidence
100%
Strong
Level of agreement
Level of evidence
100%
Strong
Level of agreement
Level of evidence
100%
Moderate
Level of agreement
Level of evidence
28%
Weak
Level of agreement
Level of evidence
39%
Weak
Level of agreement
Level of evidence
100%
Strong
Level of agreement
Level of evidence
100%
Strong
Level of agreement
Level of evidence
94%
Weak
Level of agreement
Level of evidence
100%
Weak
Level of agreement
Level of evidence
89%
Weak
Level of agreement
Level of evidence
100%
Moderate
Level of agreement
Level of evidence
100%
Strong
Level of agreement
Level of evidence
61%
Strong
Level of agreement
Level of evidence
56%
Moderate
Level of agreement
Level of evidence
33%
Weak
Level of agreement
Level of evidence
22%
Weak
Level of agreement
Level of evidence
100%
Strong
Level of agreement
Level of evidence
77%
Weak
Level of agreement
Level of evidence
100%
Strong
table_chartTABLE 1
PROFILE OF PATIENT FOR WHICH THE SBRT CONSENSUS RECOMMENDS THE USE OF HYPOFRACTIONATED RT FOR BREAST CANCER TREATMENT (AGREEMENT > 75% AMONGST PANEL MEMBERS)
| Variable | Level of agreement (%) | Level of evidence |
|---|---|---|
| Surgery Conservative | 100 | Strong |
| Mastectomy | ||
| Without reconstruction | 100 | Moderate |
| Age | ||
| >40 years | 100 | Strong |
| Stage of the tumor | ||
| T1 – T2 | 100 | Strong |
| T3 | 77 | Weak |
| Histological grade | ||
| G1 – G2 – G3 | 100 | Strong |
| Histology | ||
| Invasive carcinoma of no special type | 100 | Strong |
| DCIS | 100 | Moderate |
| Regardless of IHC | 100 | Strong |
| Axillary lymph nodes | ||
| Absent | 100 | Strong |
| Breast size | ||
| Any size | 100 | Strong |
| Systemic treatment | ||
| After adjuvant CT | 100 | Strong |
| After neoadjuvant CT | 94 | Weak |
| Concurrent with anti-HER2 drugs | 89 | Weak |
| Boost | 100 | Strong |
-
DCIS = Ductal Carcinoma IN SITU. IHC = Immunohistochemical. CT = Chemotherapy. RT = Radiotherapy
table_chartTABLE 2
DOSE-VOLUME CONSTRAINTS FOR PLANNING WHOLE-BREAST HYPOFRACTIONATED RADIOTHERAPY, ACCORDING TO THE RTOG 100525 CRITERIA
| Structure | Criteria |
|---|---|
| Breast CTV | D95% ≥ 38 (≥ 36)Gy |
| D50% ≤ 43.2 (≤ 44.8)Gy | |
| Boost CTV | D95% ≥ 9.5(9.0)Gy |
| V11Gy ≤ 5(10)% | |
| Heart | V16(20)Gy ≤ 5% |
| V8Gy ≤ 30(35)% | |
| MeanD≤ 3.2(4)Gy | |
| Lung | V16Gy ≤ 15(20)% V8Gy ≤ 35(40)% V4Gy ≤ 50(55)% |
| Contralateral lung – IMRT | V4Gy ≤ 10(15)% |
| Contralateral breast | MaxD ≤ 240(384)cGy |
| D5% ≤ 144(240)cGy |
-
CTV = clinical tumor volume, IMRT = Intensity-modulated radiotherapy, D% = dose that receives the % the volume, VGy = volume that receives the dose in Gy, MeanD = mean dose, MaxD = maximum dose
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