Radiobiological comparison of hypofractionated accelerated partial-breast irradiation (APBI) and single-dose intraoperative radiotherapy (IORT) with 50-kV X-rays

Abstract

Background and purpose: Intraoperative radiotherapy (IORT) of the tumor bed in early breast cancer is presently performed with a single dose of 50-kV X-rays from a miniaturized X-ray machine using spherical applicators. The purpose was to model the biological effect of hypofractionated accelerated partial-breast irradiation (APBI) with ten fractions.

Material and methods: The relative biologic effectiveness (RBE) was estimated from the linear-quadratic (L-Q) formalism including repair of sublethal damage or assuming a constant RBE = 1.2-1.5. The radial distribution of biological effect was assessed from clinical dose-response curves. In accordance with clinical convention, the dose for APBI was prescribed at 1 cm depth in the tumor bed, whereas for IORT it was prescribed at the applicator surface.

Results: The fraction size was fitted to give the same risk of late normal-tissue reaction (fibrosis) as single-dose IORT with a maximum dose of 20 Gy. The isoeffective fraction size at 1 cm depth varied between 1.01 Gy for RBE estimated from the L-Q model and 1.64 Gy for constant RBE. The applicator size and dose prescription point influenced the radial dose distribution. The "sphere of equivalence" within which the risk for local recurrence is the same for whole-breast radiotherapy was predicted to extend to 11-15 mm distance from the applicator for alpha/beta = 10 Gy and 9-13 mm for alpha/beta = 4 Gy for hypofractionated APBI, representing an increase of the sphere of equivalence by 2.5-6 mm relative to single-dose IORT.

Conclusion: An increase of the therapeutic window with hypofractionated APBI relative to single-dose IORT should be feasible.