Early Detection of Cardiotoxicity From Systemic and Radiation Therapy in Breast Cancer Patients
Conditions: Cardiotoxicity
Sponsor: Oncology Institute of Southern Switzerland

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Clinical Protocol Template for ClinO, Chapter 4 »Other Clinical Trials« 
Protocol Title 
 
 
 
Study Type: 
 Multicenter, observational prospective longitudinal study. 
 
Risk Categorisation:  
Risk category B 
 
Study Registration: 
 
 
Sponsor: 
 
 
 
Investigated Intervention: 
Early detection of cardiotoxicity from systemic and radiation 
therapy in breast cancer patients 
Protocol ID 
 
 
 
 
Version and Date: 
 
Version 3.0 (23.01.2020) 
 
 
CONFIDENTIALITY STATEMENT 
The information contained in this document is confidential and the property of the sponsor. The 
information may not - in full or in part - be transmitted, reproduced, published, or disclosed to 
others than the applicable Competent Ethics Committee(s) and Regulatory Authority(ies) without 
prior written authorisation from the sponsor except to the extent necessary to obtain informed 
consent from those who will participate in the study. 
 
 

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PROTOCOL SIGNATURE FORM    
 
 
Study Title 
EARLY 
DETECTION 
OF 
CARDIOTOXICITY 
FROM 
SYSTEMIC AND RADIATION THERAPY IN BREAST 
CANCER PATIENTS. 
Study ID 
 
 
The Sponsor-Investigator has approved the protocol version 3 (23.01.2020) and confirm hereby 
to conduct the study according to the protocol, current version of the World Medical Association 
Declaration of Helsinki, and ICH-GCP guidelines as well as the local legally applicable 
requirements. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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TABLE OF CONTENTS 
TABLE OF CONTENTS 
3 
GLOSSARY OF ABBREVATIONS 
4 
1 STUDY SYNOPSIS 
5 
2 BACKGROUND AND RATIONALE 
10 
3 STUDY OBJECTIVES AND DESIGN 
12 
3.1 Hypothesis and primary objective 
12 
3.2 Primary and secondary endpoints 
13 
3.3 Study design 
7 
3.4. Study intervention 
14 
4 STUDY POPULATION AND STUDY PROCEDURES 
15 
4.1 Inclusion and exclusion criteria, justification of study population 
15 
4.2 Recruitment, screening and informed consent procedure 
15 
4.3 Study procedures 
16 
4.4 Withdrawal and discontinuation 
18 
5 STATISTICS AND METHODOLOGY 
18 
5.1. Statistical analysis plan and sample size calculation 
18 
5.2. Handling of missing data and drop-outs 
19 
5 REGULATORY ASPECTS AND SAFETY 
20 
6.1 Local regulations / Declaration of Helsinki 
20 
6.2 (Serious) Adverse Events 
20 
6.3 (Periodic) safety reporting 
21 
6.4 Radiation 
21 
6.5 Pregnancy (if applicable) 
21 
6.6 Amendments 
21 
6.7 (Premature) termination of study 
22 
6.8 Insurance 
22 
7 FURTHER ASPECTS 
22 
7.1 Overall ethical considerations 
22 
7.2 Risk-benefit assessment 
22 
8 QUALITY CONTROL AND DATA PROTECTION 
22 
8.1 Quality measures 
22 
8.2 Data recording and source data 
23 
8.3 Confidentiality and coding 
23 
8.4 Retention and destruction of study data and biological material 
23 
9  MONITORING AND REGISTRATION 
10. FUNDING / PUBLICATION / DECLARATION OF INTEREST 
23 
11 REFERENCES 
24 
Appendixes 
26 
 
 

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GLOSSARY OF ABBREVATIONS 
 
AE 
Adverse Event 
ASR/DSUR 
Annual Safety Repot / Development Safety Report 
BASEC 
Business Administration System for Ethical Committees 
CMR 
Cardiac Magnetic Resonance 
CRF 
Case Report Form 
CTCAE 
Common Terminology Criteria for Adverse Events 
ECHO 
Echocardiography 
FADP 
Federal Act on Data Protection (in German: DSG, in French: LPD, in Italian: LPD) 
eCRF 
electronic Case Report Form 
FOPH 
Federal Office of Public Health 
GCP 
Good Clinical Practice 
GLS 
Global Longitudinal Strain 
HRA 
Human Research Act (in German: HFG, in French: LRH, in Italian: LRUm) 
ICH 
International Conference on Harmonisation  
ClinO 
Ordinance on Clinical Trials in Human Research (in German: KlinV, in French: 
OClin, in Italian: OSRUm) 
SAE 
Serious Adverse Event 
LVEF 
Left Ventricular Ejection Fraction 
 
 
 
 

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1 
STUDY SYNOPSIS 
Sponsor / 
Sponsor-
Investigator 
Dr.ssa Mariacarla Valli 
Study Title 
EARLY DETECTION OF CARDIOTOXICITY FROM SYSTEMIC AND RADIATION 
THERAPY IN BREAST CANCER PATIENTS.  
A MULTICENTER OBSERVATIONAL PROSPECTIVE LONGITUDINAL STUDY 
Short Title / 
Study ID 
CARDIOTOX-BREAST 
Protocol Version 
and Date 
Version 3.0 (dated 23.01.2020) 
Study 
Registration 
 
Study Category 
and Rationale 
Multicenter, observational prospective longitudinal study. 
Background and 
Rationale  
Incidence of breast cancer is rising worldwide. Due to developments in systemic and local 
therapies, median survival of early breast cancer patients has increased (Waks et al. 2019). 
Treatment of early breast cancer is multimodal and usually consists of surgery, systemic 
therapy and radiation therapy.  
As patients are living longer, it is important to decrease the rate of side effects from treatment 
and increase patients quality of life. This includes prevention and early detection of 
cardiotoxicity as many of the current treatments are potentially cardiotoxic. 
Cardiovascular complications from cancer therapy are a very heterogenous group- e.g 
myocardial dysfunction, heart failure (HF), coronary artery disease, valvular disease, 
arrhythmias, arterial hypertension, etc. Myocardial dysfunction and HF are the most frequent 
cardiac problems with breast cancer treatment. Cardiotoxicity from breast cancer treatment is 
the main mortality reason after malignancy in these patients (Barish et al 2019). It is belived, 
that cardiotoxicity is a continuous phenomenon beginning with myocardial injury, changes in 
myocardial strain and followed by progressive LVEF decline that may gradually lead to 
symptomatic heart failure (Cardinale et al. 2018). 
Anthacyclines cause irreversible cardiac damage usually characterized by continuous 
progressive decline in LVEF, which is dose-dependant and can lead to dilatated heart failure. 
However, it is hard to predict which patients develop these side effects as some patients can 
tolerate standard-dose of anthracyclines without long-term complications. On the other hand 
treatment-related cardiotoxicity may occur as early as after the first dose in other patients. 
(ESC Position Paper 2016). Many affected patients may initially be asymtomatic and clinical 
manifestations appear years later, often in the context of other triggering factors (ESC Position 
Paper 2016). Anthracyclines induced cardiotoxicity may present during or immediately after 
the infusion (acute), within the first year of treatment (early) and years after treatment (late) 
(Curigliano et al 2012, Cardinale et al 2015).  
Trastuzumab-induced cardiotoxicity is usually reversible with drug interruption and/or 
treatment with HF therapies. Toxicity from type II agents are not cumulative-dose related and 
usually develops during treatment (ESC Position Paper 2016). 
The incidence of cardiotoxicity from trastuzumab is 1,7-20,1% and from anthracycline 3-48%. 
Radiation induced cardiotoxicity (RICT) usually develops years after RT. Interstitial myocardial 
fibrosis is common in RICT. Also RT may be associated with a higher incidence of ischaemic 
heart disease through the development of severe atherosclerotic and non-atherosclerotic 
disease, complicated by plaque rupture and thrombosis, and potentially with coronary spasm 
(ESC Position paper 2016). We have to be aware that the critical portions of the heart (e.g LV, 
LAD) can receive more than 40 Gy, although the mean heart dose may be low, because the 
majority of the heart is receiving almost 0 Gy, (Cahlon et al. 2017). The actual incidence of 
radiation-induced cardiotoxicity is difficult to evaluate. Some studies have found a relative risk 
of fatal cardiovascular events between 1 and 2.2 in patients with breast cancer. Studies have 
suggested a synergistic effect on cardiac risk with left breast RT and cardiotoxic chemotherapy. 

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Systolic dysfunction is generally observed when RT is combined with anthracyclines (Jaworski 
et al 2013). 
The 2014 American Society of Echocardiograpy guidelines recommend baseline troponin at 
the initiation of both type I and II systemic therapy agents and the measurement of troponin 
before and 24 hours after each systemic therapy cycle to aid in detection of subclinical 
cardiotoxicity.  
Troponin and BNP are well studied in many trials, unfortunately with different results. Several 
studies have shown that elevation of TnI may predict the development of future LVEF 
depression and pro-BNP can predict the risk for radiation induced cardiotoxicity (Zagar et al. 
2016, Cardinale et al. 2018). Of note, one study has showed that a reduction in longitudinal 
strain and an increase in high-sensitivity troponin, after the end of anthracycline therapy, 
predicted future left ventricular dysfunction (Cardinale et al. 2018). 
Several epidemiologic studies have shown a significant association between elevated plasma 
concentrations of high-sensitivity CRP and the prevalence of underlying atherosclerotic 
vascular disease, the risk of recurrent cardiovascular events among patients with established 
disease, and among apparently healthy individuals (Ridker et al. 2000, 2008 and 2017).  
Onitilo and his colleagues published a pilot study in 2012 about hs-CRP as a biomarker for 
trastuzumab-induced cardiotoxicity. They showed, that abnormal hs-CRP (≥3 mg/L) predicted 
decreased LVEF with a sensitivity of 92.9 % (Onitilo et al 2012). 
We are still in need of sensitive and specific biomarkers, which could diagnose preclinical 
cardiotoxicity induced by breast cancer therapies.  
Echocardiography (ECHO) is currently the standard method for detecting cardiotoxicity, 
usually by monitoring serial LVEF. Three dimensional is preferred over 2 dimensional because 
of better reproducibility (Galderisi et al. 2019). Unfortunately LVEF is not directly correlated to 
early toxicity and usually reduces months after myocardial cell injury has happened. 
The use of global longitudinal strain (GLS) by speckle tracking echocardiography is strongly 
recommended becuse of its feasibility and biological reproducibility (Galderisi et al. 2019).  
Also, GLS is changing earlier than LVEF, corresponding to myocardial deformation, so this 
technique could diagnose cardiotoxicity earlier, during subclinical myocardial dysfunction 
phase (Zagar et al. 2016, Charbonnel et al 2016). 
Current guidelines suggest ECHO at baseline- before potentially cardiotoxic treatment, after 
the end of anthracycline therapy/before the start of trastuzumab treatment and every 3 months 
during trastuzumab treatment. 
Cardiac Magnetic Resonance (CMR) is the most accurate methodology for the evaluation of 
volumes and function of heart chambers. Additionally, it is exquisitely capable of providing 
myocardial tissue characterization, including specifically the presence and extension of 
myocardial edema and fibrosis. 
Serial CMR imaging in women treated for breast cancer with anthracycline-based 
chemotherapy showed reduction in LVEF 12 to 24 months after initiating therapy. Few recent 
studies have suggested that LVEF could start to decline earlier, but the prognostic implications 
of these early changes are not yet known. Recent preliminary experimental data suggest that 
the decline in contractile function is preceded by CMR evidence of myocardial edema with T2 
sequences and T2 mapping (Farhad et al. 2016, Arriola et al. 2019, Jordan et al. 2014).  
Moreover, breast cancer patients, who receive radiation therapy, have an increased risk for 
acute asymptomatic pericardial effusion, which can also be distinguished by CMR. 
CMR is the most sensitive and reproducible measure of LVEF. To our knowledge early 
radiation therapy cardiotoxicity has not been evaluated with CMR.  
When biomarkers and cardiac imaging methods (eg GLS on ECHO or oedema on CMR) are 
integrated, we can detect preclinical cardiotoxicity and prevent left ventricular dysfunction. 
Unfortunately so far the studies have had a small sample size and consequently we cannot 
evalute any practice chancing conclusion. 
This is why it is important to have baseline (before any cardiotoxic treatment) CMR together 
with biomarkers and LVEF with GLS measured on ECHO. Without baseline imaging, it is 
impossible to evaluate changes after systemic and radiation therapy as all individuals have 
different normal values. 
To our knowledge, our proposed study is the first longitudinal prospective one, which includes 
200 patients. Its primary endpoint is to evalute myocardial oedema on CMR after cardiotoxic 
systemic and radiation therapy in predicting the incidence of cardiotoxicity.  

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It is important to distinguish these high risk patients who need intensive cardiovascular 
screening during and after cardiotoxic treatment. Our purpose is find these risk group patients 
when the toxicity is still subclinical and reversible and prevent the subclinical toxicity with 
protective drugs administered to the right patient at the right time. 
Risk / Benefit 
Assessment 
Predicting the incidence of cardiotoxicity in stage I-III breast cancer patients treated with 
radiation therapy and neo/adjuvant chemo/immunotherapy +/- aromatase 
inhibitor/tamoxifen/LhRh agonist, as by International Guidelines. 
Objective(s) 
To assess the role of myocardial oedema on CMR (T2 mapping) after radiation therapy and 
cardiotoxic systemic therapy in predicting the incidence of cardiotoxicity, defined as by 
consensus guidelines* (decline of LVEF ≥10% points with a final LVEF <53%) measured on 
CMR and ECHO over the time window of 12 months from the end of radiation therapy.  
 
*American Society of Echocardiography and European Association of Cardiovascular Imaging 
Expert Consensus 
Endpoint(s) 
Secondary objectives: 
1. 
To detect GLS decrease >15% from baseline, measured on Echo over the time 
window of 12 months 
2.           To assess the incidence of myocardial oedema on CMR (T2 mapping) after radiation 
therapy and cardiotoxic systemic therapy measured on CMR and ECHO over the time window 
of 12 months from the end of radiation therapy. 
3. 
To see if the changes in biomarkers will correlate with LVEF measurements, 
assessed by ECHO and CMR 
4. 
To see if the changes in biomarkers will correlate with GLS measurements, assessed 
by ECHO  
5. 
To compare the time to the biomarkers positivity to the time to the decrease in GLS 
>15% and/or decline of LVEF ≥10% points with a final LVEF <53% measured on Echo. 
6. 
To find out if patients with increased baseline biomarkers will develop cardiotoxicity, 
identify predictors of cardiotoxicity by multivariable analysis  
7. 
To detect major cardiovascular events (defined as acute myocardial infarction, 
hospitalization due to heart failure, atrial flutter/fibrillation, ventricular tachycardia) or death due 
cardiac problems during the follow up 
8. 
To assess the role of fibrosis on CMR (T1 mapping with evaluation of extracellular 
volume) after cardiotoxic radiation therapy and systemic therapy in predicting the incidence of 
cardiotoxicity. 
9. 
To detect incidence of acute asymptomatic pericarditis after radiation therapy, 
measured on CMR  
10. 
To investigate if the area of the edema on CRM correlates with RT dose distribution 
Study Design 
This is a multicenter, observational prospective longitudinal study. 
Statistical 
Considerations 
Sample size of this multicenter study is evaluated based on feasibility. We hypothesize to be 
able to enroll 150-200 patients satisfying the enrollment criteria and giving consent to 
participate into the study. We base calculations on the primary endpoint. 
From previous experience we expect a rate of cardiac toxicity around 17% at 12 months. We 
use a alpha level of 10% one-sided, given the lack of strong evidence in the literature (“early 
evidence” study).  
We used Stata 15 (StataCorp, College Station, TX, USA) for computation. 
Analyses will be performed using Stata 15 or later versions by the study statistician. Data at 
enrollment will be described as mean and standard deviation or median and 25th-75th 
percentiles if continuous and as counts and percent if categorical. They will be compared 
between groups of patients with and without oedema at the end of RT with the Student t test 
(or the Mann Whitney U test, based on the distribution) and with the Fisher exact test, 
respectively.  
Analysis of the primary endpoint. The proportion of patients with cardiac toxicity at 12 months 
will be compared between groups. The mean difference in proportions of cardiac toxicity at 12 
months and its 80% confidence interval (CI) will be reported. Logistic regression will be used 
to adjust for potential confounders. Patients who die or are lost before the 12th month 
assessment will be considered as having toxicity. We do not expect losses to follow-up. A 
sensitivity analysis will classify them as no cardiac toxicity patients. If the mortality and/or 

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losses to follow-up are above 10% will also compare groups using survival analysis methods 
to account for the different follow-up between patients, using the same strategies. 
Analysis of the secondary endpoints. Proportions will be compared as described above. Time 
to event endpoints will be compared using survival analysis methods. Correlation between 
changes in biomarkers and changes cardiac in cardiac function will be assessed with linear 
regression models. Data transformation will be applied as needed. 
Multivariable analysis to identify potential predictors of cardiac toxicity will be performed if 
allowed, given the 1:10 thumb rule between predictors and events. 
An ancillary study will enroll also stage 0 patients (appendix 2). 
Inclusion- 
/ 
Exclusion 
Criteria 
Participants eliglible for this study will include female patients aged ≥ 18 years, stage I-III breast 
cancer, treated with potentially cardiotoxic therapies at the participating centers over 2-3 years 
Inclusion criteria: 
Patients eligible for inclusion in this study must fulfill all of the following criteria: 
1. 
Written informed consent must be obtained before any assessment is performed 
2. 
Age ≥ 18 years at visit 1 
3. 
Performance status ECOG 0-1 
4. 
*Stage I-III histology proven breast cancer  
5. 
Treated with adjuvant radiotherapy and neo/adjuvant anthracycline and/or 
trastuzumab-based therapy +/- hormonal therapy 
6. 
Negative pregnancy test (plasma HCG) for all females of childbearing potential (i.e 
not permanently sterilised- post hysterectomy or tubal ligation status) 
 
Patients will be excluded if they meet any of the following criteria:  
1. 
Known metastatic spread of any cancer 
2. 
Known active or recurrent hepatic disorder (cirrhosis, hepatitis), ASAT/ALAT 2xULN 
3. 
Renal function decrease (eGFR < 30 ml/min) 
4. 
Known coronary artery disease 
5. 
Angina pectoris 
6. 
Positive or missing pregnancy test (pre- and perimenopausal women) at enrolment 
visit  
7. 
Patients with baseline LVEF <53% and GLS <15% 
8.  
Patients with pacemaker 
 
*In the ancillary study patients with stage 0 (DCIS) histology proven breast cancer will also be 
included. 
Number 
of 
Participants with 
Rationale 
Sample size of this multicenter study is evaluated based on feasibility. We hypothesize to be 
able to enroll 150-200 patients satisfying the enrollment criteria and giving consent to 
participate into the study. We base calculations on the primary endpoint. 
Study Interventio 
NA 
Control 
Intervention 
This study does not include control group. 
Study 
procedures 
Overall study schedule 
The Overall Study Schedule is summarized in the assessment schedule (appendix 1). 
This study is composed of three subsequent phases: a Run-In Phase, a RT/Systemic Therapy 
Phase, a Follow-Up Phase. 
 
Run-In Phase 
The Run-In Phase starts with the first visit (before any cancer treatment), when 
Screening/Enrollment procedure is performed. This phase will start once a patient has 
provided WIC to participate in the study and ends the day of treatment start. 
 
Screening / Enrolment Visit  
Visit will be performed before the expected starting date of treatment. 
After a WIC has been obtained from the patient, the patient will be visited by the Investigators 
and the following information will be gathered: 
• Demographic Data (age, height, weight, BMI); 
• Medical history (previous and concomitant diseases, previous therapies, family history of 
CVD); 

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• Concomitant Medication; 
• Physical examination & overall health assessment (including vital signs). 
• Pregnancy test (pre- and perimenopausal women). 
The inclusion and exclusion criteria will be checked and, if the patient complies with all the 
Inclusion and Exclusion criteria, she will be enrolled into the study 
A baseline assessment will be performed by the Investigator:  
CMR, ECG and ECHO will be done at the participating centers  
The patient will be assigned to specific treatment (chemo/immunotherapy and adjuvant 
radiation therapy +/- aromatase inhibitor/tamoxifen/LhRh agonist). A standard of care 
treatment will be administered.  
 
Radiotherapy/Systemic therapy Treatment Phase (specific Visit descriptions) 
SYSTEMIC TREATMENT 
Blood sample will be scheduled before and, if possible, 24 hours after chemotherapy 
administration. 
-Patients treated with antracyclines regimens will be checked with ECG and ECHO at the end 
of treatment. 
-Blood sample will be scheduled before Trastuzumab administration every three weeks and 
ECHO will be done after every 4 cycles (3 months). 
 
RADIOTHERAPY  
For Technical details see appendix 3.  
Before starting RT patients will be checked clinically the first day of treatment and baseline 
tests will be done. 
Biomarkers will be checked the first day and in the middle of RT. 
If a patient gets symptomatic heart failure during the treatment, or if LVEF decline greater than 
10% points with a final LVEF <53% measured on Echo, the patient will be referred to the 
cardiologist for a specific treatment as described by guidelines  
 
End of RT Group  
Patients treated with trastuzumab, will continue the treatment up to 1 year. Blood tests will be 
taken every three weeks and Echos will be done after every 4 cycles (3-week cycles). 
 
Follow-Up Phase 
2 weeks+/-3 days after the end of RT, blood sample will be taken. An ECHO and CMR will be 
done. 
All patients will be checked 6 weeks after the end of radiotherapy for the study visit.  
The following activities will be performed: 
Blood sample for biomarkers. 
If hs-CRP ≥3mg/l, ECHO will be done.  
All patients will be followed at least until 10 years after the end of RT.  
Blood samples for measuring biomarkers and ECHO and CMR will be done 12 months after 
the end of RT.  
 
Unscheduled Visit 
An unscheduled visit may occur at any time during the study, only for safety reason or for a 
premature discontinuation from the study. 
Study 
Duration 
and Schedule 
Planned 02/2020 of First-Participant-In 
Planned 12/2022 of Last-Participant-Out 
Investigator(s) 
 
 
4 centers in 3 countries will be involved: 
1) 
Istituto Oncologico della Svizzera Italiana Lugano/Bellinzona (IOSI), Via Ospedale, 
6500 Bellinzona, Switzerland 
2) 
Cardiocentro Ticino Lugano (CCT), Via Tesserete 48, 6900 Lugano, Switzerland 
3) 
North Estonia Medical Center (NEMC), Sutise tee 19, 13419 Tallinn, Estonia 
4) 
Ospedale Universitario S. Matteo, Pavia, Italia 
Data privacy 
Data will be collected in a dedicated database in Filemaker 11. The database will be resident 
on a Server at CCT. Backup will be performed according to the local operating procedures. 

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Data will be pseudoanonymized with a unique personal number (UPN). It is the responsability 
of the PI at each Center to keep a logbook to maintain the link of patient ID and the code. No 
identifiers will be included in the database. Data entry will be performed via web. Access will 
be regulated by a center username and account. Each Center will be able to see and modify 
its own records only. The study PI will be able to see all records. Export of the database will 
be allowed to the study statistician. 
Ethical 
consideration 
Patients are treated according to current best practice and International Guidelines.  
Based on the assumptions of the study and the sponsor's previous clinical experience 
as well as current scientific knowledge, it is possible that by participating in the study patients 
may benefit from a diagnostic evaluation with CMR. 
Our aim is to diagnose a possible event when it is still subclinical and reversible and to prevent 
its evolution with protective drugs. 
Distinguish asymptomatic patients who are at risk of cardiotoxicity and, if possible, avoid side 
effects with protective treatment. 
This study does not involve any risks to patients. 
GCP Statement 
This study will be conducted in compliance with the protocol, the current version of the 
Declaration of Helsinki, the ICH-GCP, the HRA as well as other locally relevant legal and 
regulatory requirements.  
 
2 
BACKGROUND AND RATIONALE  
Incidence of breast cancer is rising worldwide. Due to developments in systemic and local 
therapies, median survival of early breast cancer patients has increased (Waks et al. 2019). 
Treatment of early breast cancer is multimodal and usually consists of surgery, systemic therapy 
and radiation therapy.  
Local therapy for nonmetastatic breast cancer patients consists of surgical operation (lumpectomy 
or mastectomy and sentinel lymph node biopsy or axillary lymph node dissection). Depending on 
the type of operation and stage, adjuvant radiation therapy is prescribed to decrease the risk of 
disease recurrence and reducing the risk for breast cancer death (EBCTCG et al 2018). 
Systemic therapy is an essential part of treatment for preventing recurrence in many patients with 
stage I-III breast cancer. It includes hormonal-, chemo- and/or biological therapy. Anthracycline-
based regimens are one of the most effective treatments for patients with breast cancer. Early 
Breast Cancer Trialists' Collaborative Group meta-analysis showed that these regimens decrease 
breast cancer mortality by about 20% (EBCTCG et al. 2012). Not all early stage breast cancer 
patients need chemotherapy: the decision depends on the stage, tumor grade, molecular 
subtypes, genomic risk score and patients preference. 20% of breast cancers has ErbB-2 protein 
overexpression or ErbB-2 gene amplification. These patients benefit from ErbB-2-targeted 
therapy (e.g 1 year of trastuzumab) (Waks et al. 2019). 
As patients are living longer, it is important to decrease the rate of side effects from treatment and 
increase patients quality of life. This includes prevention and early detection of cardiotoxicity as 
many of the current treatments are potentially cardiotoxic. 
Cardiovascular complications from cancer therapy are a very heterogenous group- e.g myocardial 
dysfunction, heart failure (HF), coronary artery disease, valvular disease, arrhythmias, arterial 
hypertension, etc. Myocardial dysfunction and HF are the most frequent cardiac problems with 
breast cancer treatment. Cardiotoxicity from breast cancer treatment is the main mortality reason 
after malignancy in these patients (Barish et al 2019). It is belived, that cardiotoxicity is a 
continuous phenomenon beginning with myocardial injury, changes in myocardial strain and 
followed by progressive LVEF decline that may gradually lead to symptomatic heart failure 
(Cardinale et al. 2018). 
When heart failure treatment in these patients is delayed, it is relatively possible that their cardiac 
function will never restores as it was baseline (Zagar et al. 2016). That is why it is important to 
distinguish asymptomatic patients who are at risk for cardiotoxicity and if possible, avoid side 
effects with protective treatment. 
Anthacyclines are considered as the prototype of type I cardiotoxic agents (Curigliano et al 2012). 
It is belived that agents, belonging to this group, cause irreversible cardiac damage usually 

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characterized by continuous progressive decline in LVEF, which is dose-dependant and can lead 
to dilatated heart failure. However, it is hard to predict which patients develop these side effects 
as some patients can tolerate standard-dose of anthracyclines without long-term complications. 
On the other hand treatment-related cardiotoxicity may occur as early as after the first dose in 
other patients. (ESC Position Paper 2016). Many affected patients may initially be asymtomatic 
and clinical manifestations appear years later, often in the context of other triggering factors (ESC 
Position Paper 2016,). Anthracyclines induced cardiotoxicity may present during or immediately 
after the infusion (acute), within the first year of treatment (early) and years after treatment (late) 
(Curigliano et al 2012, Cardinale et al 2015).  
Trastuzumab is considered to be type II cardiotoxic agent (Curigliano et al 2012). Trastuzumab-
induced cardiotoxicity is usually reversible with drug interruption and/or treatment with HF 
therapies. Toxicity from type II agents are not cumulative-dose related and usually develops 
during treatment (ESC Position Paper 2016). 
The incidence of cardiotoxicity from trastuzumab is 1,7-20,1% and from anthracycline 3-48%. 
It varies between studies and so does the definition of cardiotoxicity. American Society of 
Echocardiography and European Association of Cardiovascular Imaging Expert Consensus 
defines cardiotoxicity as a decline of left ventricular ejection fraction (LVEF) ≥10% points with a 
final LVEF <53%. 
Due to their potential cardiotoxicity, anthracycline and trastuzumab are usually not administred 
concurrently. Trastuzumab can be combined with taxanes (ESC Position Paper 2016). 
If the patient needs adjuvant chest wall or breast radiation therapy (RT), it is usually given together 
with trastuzumab. Studies have not found any increased risk of cardiotoxicity due to concurrent 
use of these treatments (Sari et al. 2016). 
Radiation induced cardiotoxicity (RICT) usually develops years after RT. Interstitial myocardial 
fibrosis is common in RICT. Also RT may be associated with a higher incidence of ischaemic 
heart disease through the development of severe atherosclerotic and non-atherosclerotic disease, 
complicated by plaque rupture and thrombosis, and potentially with coronary spasm (ESC 
Position paper 2016). Older studies have suggested that this phenomen manifests more than 10 
years after the end of radiation therapy (Zagar et al 2016). New tehniques (e.g deep inspiration 
breath hold, 3D CT-based planning) should lower the risk for cardiotoxicity. Darby et al. 
metaanalysis evidenced that there are no “safe” radiotherapy dose to the heart. Also, there is a 
7,4% increase in relative risk of major cardiac event for each additional 1 Gy of mean heart dose. 
This metaanalysis also confirmed that RICT begins in the first few years after treatment (Darby 
et al 2013, Cahlon et al 2017). We have to be aware that the critical portions of the heart (e.g LV, 
LAD) can receive more than 40 Gy, although the mean heart dose may be low, because the 
majority of the heart is receiving almost 0 Gy, (Cahlon et al. 2017). The actual incidence of 
radiation-induced cardiotoxicity is difficult to evaluate. Some studies have found a relative risk of 
fatal cardiovascular events between 1 and 2.2 in patients with breast cancer. Studies have 
suggested a synergistic effect on cardiac risk with left breast RT and cardiotoxic chemotherapy. 
Systolic dysfunction is generally observed when RT is combined with anthracyclines (Jaworski et 
al 2013). 
The 2014 American Society of Echocardiograpy guidelines recommend baseline troponin at the 
initiation of both type I and II systemic therapy agents and the measurement of troponin before 
and 24 hours after each systemic therapy cycle to aid in detection of subclinical cardiotoxicity.  
Troponin and BNP are well studied in many trials, unfortunately with different results. Several 
studies have shown that elevation of TnI may predict the development of future LVEF depression 
and pro-BNP can predict the risk for radiation induced cardiotoxicity (Zagar et al. 2016, Cardinale 
et al. 2018). Of note one study has showned that a reduction in longitudinal strain and an increase 
in high-sensitivity troponin, after the end of anthracycline therapy, predicted future left ventricular 
dysfunction (Cardinale et al. 2018). 
Several epidemiologic studies have shown a significant association between elevated plasma 
concentrations of high-sensitivity CRP and the prevalence of underlying atherosclerotic vascular 
disease, the risk of recurrent cardiovascular events among patients with established disease, and 
among apparently healthy individuals (Ridker et al. 2000, 2008 and 2017).  

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Onitilo and his colleagues published a pilot study in 2012 about hs-CRP as a biomarker for 
trastuzumab-induced cardiotoxicity. They showed, that abnormal hs-CRP (≥3 mg/L) predicted 
decreased LVEF with a sensitivity of 92.9 %. 
Still we are in need of sensitive and specific biomarkers, which could diagnose preclinical 
cardiotoxicity induced by breast cancer therapies.  
Echocardiography (ECHO) is currently the standard method for detecting cardiotoxicity, usually 
by monitoring serial LVEF. Three dimensional is preferred over 2 dimensional because of better 
reproducibility (Galderisi et al. 2019). Unfortunately LVEF is not directly correlated to early toxicity 
and usually reduces months after myocardial cell injury has happened. 
The use of global longitudinal strain (GLS) by speckle tracking echocardiography is strongly 
recommended becuse of its feasibility and biological reproducibility (Galderisi et al. 2019).  
Also, GLS is changing earlier than LVEF, corresponding to myocardial deformation, so this 
tehnique could diagnose cardiotoxicity earlier, during subclinical myocardial dysfunction phase 
(Zagar et al. 2016, Charbonnel et al 2016). 
Current guidelines suggest ECHO at baseline- before potentially cardiotoxic treatment, after the 
end of anthracycline therapy/before the start of trastuzumab treatment and every 3 months during 
trastuzumab treatment. 
Cardiac Magnetic Resonance (CMR) is the most accurate methodology for the evaluation of 
volumes and function of heart chambers. Additionally, it is exquisitely capable of providing 
myocardial tissue characterization, including specifically the presence and extension of 
myocardial edema and fibrosis. 
Serial CMR imaging in women treated for breast cancer with anthracycline-based chemotherapy 
showed reduction in LVEF 12 to 24 months after initiating therapy. Few recent studies have 
suggested that LVEF could start to decline earlier but the prognostic implications of these early 
changes are not yet known.Recent preliminary experimental data suggest that the decline in 
contractile function is preceded by CMR evidence of myocardial edema with T2 sequences and 
T2 mapping (Farhad et al. 2016, Arriola et al. 2019, Jordan et al. 2014).  
Moreover breast cancer patients, who receive radiation therapy, have an increased risk for acute 
asymptomatic pericardial effusion, which can also be distinguished by CMR. 
CMR is the most sensitive and reproducible measure of LVEF. To our knowledge early radiation 
therapy cardiotoxicity has not been evaluated with CMR.  
When biomarkers and cardiac imaging methods (eg GLS on ECHO or oedema on CMR) are 
integrated, we can detect preclinical cardiotoxicity and prevent left ventricular dysfunction. 
Unfortunately so far the studies have had a small sample size and consequently we cannot 
evalute any practice chancing conclusion. 
This is why it is important to have baseline (before any cardiotoxic treatment) CMR together with 
biomarkers and LVEF with GLS measured on ECHO. Without baseline imaging, it is impossible 
to evaluate changes after systemic and radiation therapy as all individuals have different normal 
values. 
To our knowledge, our proposed study is the first longitudinal prospective one which includes 200 
patients. Its primary endpoint is to evalute myocardial oedema on CMR after cardiotoxic systemic 
therapy and radiation therapy in predicting the incidence of cardiotoxicity.  
It is important to distinguish these high risk patients who need intensive cardiovascular screening 
during and after cardiotoxic treatment. Our purpose is find these risk group patients when the 
toxicity is still subclinical and reversible and prevent the subclinical toxicity with protective drugs 
administered to the right patient at the right time. 
3 
STUDY OBJECTIVES AND DESIGN  
3.1 Hypothesis and primary objective 
Describe a clear hypothesis that will be answered through the study and the primary objective. In 
rare cases a hypothesis might not be required (e.g. exploratory studies).  
 
 

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The primary objective of this trial is to find out if myocardial oedema on CMR (T2 mapping) after 
radiation and cardiotoxic systemic therapy is predicting the incidence of early cardiotoxicity, 
defined as by consensus guidelines (decline of LVEF ≥10% points with a final LVEF <53%). 
3.2 Primary and secondary endpoints 
The primary endpoint is the main result that is measured during or at the end of an intervention 
to verify whether the intervention (i.e. the administrated treatment, the surgical procedure, the 
physiotherapy etc.) was successful or not. Describe the variable of primary interest, the rationale 
for its selection, the method and as applicable the time point of assessment. In general, a single 
variable and a single time point are used for the primary endpoint. Under certain circumstances, 
a combined primary endpoint is possible, but should be carefully determined together with trial 
statistician. 
If applicable, provide a description of all secondary endpoint variables to be assessed. The 
secondary endpoint(s) are used to answer the secondary objectives. 
If applicable, provide a description of the safety endpoint variables referring to e.g. specific 
adverse events (AEs), the rate of adverse events in general, laboratory parameters/vital signs, 
etc. 
Describe baseline factors that may have an influence on the endpoints (e.g. age, gender, history, 
morbidity etc.). 
 
Primary Endpoint 
To assess the role of myocardial oedema on CMR (T2 mapping) after radiation and cardiotoxic 
systemic therapy in predicting the incidence of cardiotoxicity, defined as by consensus guidelines* 
(decline of LVEF ≥10% points with a final LVEF <53%) measured on CMR and ECHO over the 
time window of 12 months from the end of radiation therapy.  
 
*American Society of Echocardiography and European Association of Cardiovascular Imaging 
Expert Consensus  
 
Secondary Endpoints 
1. 
To detect GLS decrease >15% from baseline, measured on Echo over the time window 
of 12 months 
2. 
To see if the changes in biomarkers will correlate with LVEF measurements, assessed by 
ECHO and CMR 
3. 
To see if the changes in biomarkers will correlate with GLS measurements, assessed by 
ECHO  
4. 
To compare the time to the biomarkers positivity to the time to the decrease in GLS >15% 
and/or decline of LVEF ≥10% points with a final LVEF <53% measured on Echo. 
5. 
To find out if patients with increased baseline biomarkers will develop cardiotoxicity, 
identify predictors of cardiotoxicity by multivariable analysis  
6. 
To detect major cardiovascular events (defined as acute myocardial infarction, 
hospitalization due to heart failure, atrial flutter/fibrillation, ventricular tachycardia) or death due 
cardiac problems during the follow up 
7. 
To assess the role of fibrosis on CMR (T1 mapping with evaluation of extracellular volume) 
after cardiotoxic radiation therapy and /or systemic therapy in predicting the incidence of 
cardiotoxicity. 
8. 
To detect incidence of acute asymptomatic pericarditis after radiation therapy, measured 
on CMR  
9. 
To investigate if the area of the edema on CRM correlates with RT dose distribution 

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10.     To assess the incidence of myocardial oedema on CMR (T2 mapping) after radiation 
therapy and cardiotoxic systemic therapy measured on CMR and ECHO over the time window of 
12 months from the end of radiation therapy. 
3.3 Study design  
Both the study design and the selected methods should be appropriate to answer the research 
question and address the hypothesis.  
Describe the general study design (e.g. confirmatory, non-randomised / randomised, one-arm / 
two-arms, open / single-blinded / cross-over) and the study setup (monocentric / multicenter, 
national / international). Discuss known or potential problems associated with the trial design. 
Describe the methods of minimising bias (e.g. randomisation or other methods of minimising bias, 
such as the use of validated questionnaires). 
 
This is a multicentric, observational prospective longitudinal study. 
The study will be submitted for an approval by Ethical Committees and will be conducted in 
agreement with the principles of Good Clinical Practice and the Declaration of Helsinki. 
This study is designed to evaluate myocardial oedema on CMR after radiation therapy and 
cardiotoxic systemic therapy in predicting the incidence of cardiotoxicity. 
Stage I-III female breast cancer patients, who are planning on starting neo/adjuvant therapy for 
breast cancer at the participating centers (appendix 4) are asked to join the study. After the eligible 
patient has signed her written informed consent, she will start with scheduled visits and 
examinations as shown in the study assessment schedule.  
Baseline blood tests will be taken, physical examination, CMR, ECG and ECHO will be done, 
proper medical history, including current medications of the patient and family history of CVD will 
be taken. If baseline hs-CRP ≥10 mg/l, another blood test will be checked after 2 weeks. 
ECHO will be done on Philips Epiq or General Electic Vivid E95 and Cardiac Magnetic Resonance 
will be performed with Siemens Skyra 3T or a 1.5T scanner (MAGNETOM Aera, Siemens AG). 
Parameters measured and protocol is listed in appendix 5.  
Patients receiving cardiotoxic chemotherapy will be drown blood before and if possible 24 hours 
after chemotherapy administration.  
Patients who get anthracycline, have an ECHO and ECG after the end of this treatment.  
During trastuzumab, blood will be taken before every administration (every 3 weeks) and ECHO 
will be done after every 4 cycles (every 3 months). 
Before the beginning of radiotherapy, blood tests will be taken, CMR and ECHO will be done. 
Patients who receive trastuzumab concurrently with RT will continue visits as described above.  
Biomarkers will be taken in the middle of RT. 
2 weeks +/-3 days after the end of RT, blood tests will be taken, CMR and ECHO will be done. 
Six weeks after the end of RT, biomarkers will be measured. If hs-CRP ≥3mg/l, ECHO will be 
done.  
Patients will be followed at least until 10 years after the end of RT.  
12 months after the end of RT blood tests for measuring biomarkers and ECHO and CMR will be 
checked.  
During treatment, if a patient gets symptomatic heart failure or decline of LVEF greater than 10% 
points, with a final LVEF <53% on ECHO, patient will be referred to cardiologist and specific 
treatment as described by guidelines will be prescribed. 
3.4. Study intervention 
Patients are treated by standard of care treatment. This study includes extra diagnostics (CMR, 

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ECHO and blood tests). Study procedures are discussed at section 4.3. 
 
4 
STUDY POPULATION AND STUDY PROCEDURES 
4.1 Inclusion and exclusion criteria, justification of study population 
Describe the study population and specify the total number of participants, including the control 
groups. Justify the choice of study population.  
 
The study will enroll about 150- 200 female patients aged ≥ 18 years with stage I-III breast cancer 
treated with radiation therapy and neo/adjuvant chemo/immunotherapy +/- aromatase 
inhibitor/tamoxifen/LhRh agonist, as by International Guidelines.  
An ancillary study will enroll also stage 0 patients (appendix 2). 
This study does not include control group. 
 
Inclusion criteria: 
Patients eligible for inclusion in this study must fulfill all of the following criteria: 
1. 
Written informed consent must be obtained before any assessment is performed 
2. 
Female, Age ≥ 18 years at visit 1 
3. 
Performance status ECOG 0-1 
4. 
*Stage I-III histology proven breast cancer  
5. 
Treated with adjuvant radiotherapy and neo/adjuvant anthracycline and/or trastuzumab-
based therapy +/- hormonal therapy 
6. 
Negative pregnancy test (plasma HCG) for all females of childbearing potential (i.e not 
permanently sterilised- post hysterectomy or tubal ligation status-) 
 
Patients will be excluded if they meet any of the following criteria:  
1. 
Known metastatic spread of any cancer 
2. 
Known active or recurrent hepatic disorder (cirrhosis, hepatitis), ASAT/ALAT 2xULN 
3. 
Renal function decrease (eGFR < 30 ml/min) 
4. 
Known coronary artery disease 
5. 
Angina pectoris 
6. 
Positive or missing pregnancy test (pre- and perimenopausal women) at enrolment visit  
7. 
Patients with baseline LVEF <53% and GLS <15% 
8.  
Patients with pacemaker 
 
*In the ancillary study patients with stage 0 (DCIS) histology proven breast cancer will also be 
included. 
4.2 Recruitment, screening and informed consent procedure 
Patients will be recruited in participating centers, where they are planning on starting treatment 
with anthracycline and/or trastuzumab and radiation therapy for stage I-III breast cancer. The 
enrollment will be ongoing for 2-3 years until the needed number of patients are recruited. The 
study investigators will recruit patients during their daily clinical practice.  
Eligible patients may only be included in the study after providing written, IEC-approved informed 
consent (WIC) for the use of their data in the study. She will be informed that data will only be 
communicated in aggregated form.  

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The investigators will explain to each participant the nature of the study, its purpose, the 
procedures involved, the expected duration, the potential risks and benefits and any discomfort it 
may entail. Each participant will be informed that the participation in the study is voluntary and 
that she may withdraw from the study at any time and that withdrawal of consent will not affect 
his or her subsequent medical assistance and treatment.  
The participant will be informed that her medical records may be examined by authorised 
individuals other than their treating physician. 
All participants for the study will be provided a participant information sheet and a consent form 
(appendix 6, 7) describing the study and providing sufficient information for participant to make 
an informed decision about their participation in the study.  Patients have one week to decide 
whether to participate in the study or not.  
The formal consent of a participant, using the approved consent form, will be obtained before the 
participant is submitted to any study procedure.   
The consent form will be signed and dated by the investigator or his designee at the same time 
as the participant sign. A copy of the signed informed consent will be given to the study participant. 
The consent form will be retained as part of the study records.  
The screening visit will consist of collecting this data: 
• Demographic Data (age, height, weight, BMI) 
• Medical history (previous and concomitant diseases, previous therapies, family history of CVD) 
• Concomitant Medication 
• Physical examination & overall health assessment (including vital signs) 
• Pregnancy test (pre- and perimenopausal women). 
The inclusion and exclusion criteria will be checked and, if the patient complies with all the 
Inclusion and Exclusion criteria, she will be enrolled into the study 
A baseline assessment will be performed by the Investigator:  
CMR, ECG and ECHO will be done at the participating centers  
The patient will be assigned to specific treatment (chemo/immunotherapy and adjuvant radiation 
therapy +/- aromatase inhibitor/tamoxifen/LhRh agonist.). A standard of care treatment will be 
administered. 
 
Patients are treated according to current best practice and International Guidelines. No additional 
costs are foreseen in relation to the study. 
4.3 Study procedures 
The recruitment period is 2-3 years until the needed number of patients have been enrolled. Each 
patient will be followed until 12 months after the end of radiation therapy. If possible, patients will 
be followed for 10 years.  
 
Study Procedures  
Overall study schedule 
The Overall Study Schedule is summarized in the assessment schedule (appendix 1). 
This study is composed of three subsequent phases: a Run-In Phase, a RT/Systemic Therapy 
Phase, a Follow-Up Phase. 
 
 
Run-In Phase 
The Run-In Phase starts with the first visit (before any cancer treatment), when 
Screening/Enrollment procedure is performed. This phase will start once a patient has provided 
WIC to participate in the study and ends the day of treatment start. 

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Screening / Enrolment Visit  
Visit will be performed before the expected starting date of treatment. 
After a WIC has been obtained from the patient, the patient will be visited by the Investigators 
and the following information will be gathered: 
• Demographic Data (age, height, weight, BMI); 
• Medical history (previous and concomitant diseases, previous therapies, family history of CVD); 
• Concomitant Medication; 
• Physical examination & overall health assessment (including vital signs). 
• Pregnancy test (pre- and perimenopausal women). 
The inclusion and exclusion criteria will be checked and, if the patient complies with all the 
Inclusion and Exclusion criteria, she will be enrolled into the study 
A baseline assessment will be performed by the Investigator:  
CMR, ECG and ECHO will be done at the participating centers  
The patient will be assigned to specific treatment (chemo/immunotherapy and adjuvant radiation 
therapy +/- aromatase inhibitor/tamoxifen/LhRh agonist.). A standard of care treatment will be 
administered.  
 
Radiotherapy/Systemic therapy Treatment Phase  
SYSTEMIC TREATMENT 
-Blood sample will be scheduled before and, if possible, 24 hours after chemotherapy 
administration. 
-Patients treated with antracyclines regimens will be checked with ECG and ECHO at the end of 
treatment. 
-Blood sample will be scheduled before Trastuzumab administration every three weeks and 
ECHO will be done after every 4 cycles (3 months). 
 
RADIOTHERAPY  
For Technical details see appendix 3.  
-Before starting RT patients will be checked clinically the first day of treatment and baseline tests 
will be done. 
-Biomarkers will be checked the first day and in the middle of RT. 
-If a patient gets symptomatic heart failure during the treatment, or if LVEF decline greater than 
10% points with a final LVEF <53% on ECHO, the patient will be referred to the cardiologist for a 
specific treatment as described by guidelines  
End of RT Group  
Patients treated with trastuzumab, will continue the treatment up to 1 year. Blood tests will be 
taken every three weeks and ECHOs will be done after every 4 cycles (3-week cycles). 
 
Follow-Up Phase 
2 weeks+/-3 days after the end of RT, blood sample will be taken. An ECHO and CMR will be 
done. 
All patients will be checked 6 weeks after the end of radiotherapy for the study visit.  
The following activities will be performed: 
-Blood sample for biomarkers. 
If hs-CRP ≥3mg/l, ECHO will be done.  
-All patients will be followed at least until 10 years after the end of RT.  

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-Blood samples for measuring biomarkers and ECHO and CMR will be done 12 months after the 
end of RT.  
 
Unscheduled Visit 
An unscheduled visit may occur at any time during the study, only for safety reason or for a 
premature discontinuation from the study. 
 
Data will be collected in a dedicated database in Filemaker 11. The database will be resident on 
a Server at CCT. Backup will be performed according to the local operating procedures. Data will 
be pseudoanonymized with a unique personal number (UPN). It is the responsability of the PI at 
each Center to keep a logbook to maintain the link of patient iD and the code. No identifiers will 
be included in the database. Data entry will be performed via web. Access will be regulated by a 
center username and account. Each Center will be able to see and modify its own records only. 
The study PI will be able to see all records. Export of the database will be allowed to the study 
statistician. 
 
 
4.4 Withdrawal and discontinuation 
Subject has the right to withdraw from the study at any time for any reason, including 
personal reasons. Subjects prematurely withdrawing from the study will not be replaced. 
The reason for withdrawal and discontinuation of any subject from the investigation shall be 
recorded. 
A patient's participation in the investigation is to terminate immediately upon her request. Every 
patient has the right to refuse further participation in the study at any time and without providing 
reasons. We will register the reason only in case of withdraw due to disconfort with diagnostic tools. 
The Investigator should anyway seek to obtain the reason and record this on the eCRF. 
5 
STATISTICS AND METHODOLOGY 
5.1. Statistical analysis plan and sample size calculation 
Study statistician is dr.ssa Catherine Klersy. 
 
Sample size 
Sample size of this multicenter study is evaluated based on feasibility. We hypothesize to be able 
to enroll 150-200 patients satisfying the enrollment criteria and giving consent to participate into 
the study. We base calculations on the primary endpoint. 
Primary endpoint: To assess the role of myocardial oedema on CMR (T2 mapping) after 
cardiotoxic systemic therapy and radiation therapy in predicting the incidence of cardiotoxicity, 
defined as by consensus guidelines* (decline of LVEF ≥10% points with a final LVEF <53%) 
measured on CMR and ECHO over the time window of 12 months from the end of radiation 
therapy.  
 
Table 2. summarizes the effect size for the primary endpoint that can be detected for the expected 
sample size, given a power of 80% and different rates of prevalence of myocardial edema after 
cardiotoxic systemic therapy and/or radiation therapy. From previous experience we expect a rate 
of cardiac toxicity around 17% at 12 months. We use a alpha level of 10% one-sided, given the 
lack of strong evidence in the literature (“early evidence” study).  
We used Stata 15 (StataCorp, College Station, TX, USA) for computation. 

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Table 2: Effect size computation assuming a rate of cardiac toxicity at 12 months of p1=17% in 
the cohort without edema at MR. Power 80%, alpha (2-sided) 20% 
 
 
Hypotesized % of pts 
with MR oedema at the 
end of RT 
Detectable effect size in the 
edema population 
P2 [Difference]  
N=150 
Detectable effect size in the 
edema population 
P2 [Difference]  
N=200 
5% 
52% [35] 
48% [31] 
10% 
43% [26] 
39% [22] 
15% 
39% [22] 
36% [19] 
20% 
37% [20] 
34% [17] 
25% 
35% [18] 
33% [16] 
 
Statistical Analysis 
Analyses will be performed using Stata 15 or later versions by the study statistician. Data at 
enrollment will be described as mean and standard deviation or median and 25th-75th percentiles 
if continuous and as counts and percent if categorical. They will be compared between groups of 
patients with and without oedema at the end of RT with the Student t test (or the Mann Whitney 
U test, based on the distribution) and with the Fisher exact test, respectively.  
Analysis of the primary endpoint. The proportion of patients with cardiac toxicity at 12 months will 
be compared between groups. The mean difference in proportions of cardiac toxicity at 12 months 
and its 80% confidence interval (CI) will be reported. Logistic regression will be used to adjust for 
potential confounders. Patients who die or are lost before the 12th month assessment will be 
considered as having toxicity. We do not expect losses to follow-up. A sensitivity analysis will 
classify them as no cardiac toxicity patients. If the mortality and/or losses to follow-up are above 
10% will will also compare groups using survival analysis methods to account for the different 
follow-up between patients, using the same strategies. 
Analysis of the secondary endpoints. Proportions will be compared as described above. Time to 
event endpoints will be compared using survival analysis methods. Correlation between changes 
in biomarkers and changes cardiac in cardiac function will be assessed with linear regression 
models. Data transformation will be applied as needed. 
Multivariable analysis to identify potential predictors of cardiac toxicity will be performed if allowed, 
given the 1:10 thumb rule between predictors and events.  
 
CRF and data management 
Data will be collected in a dedicated database in Filemaker 11. The database will be resident on 
a Server at CCT. Backup will be performed according to the local operating procedures. Data will 
be pseudoanonymized with a unique personal number (UPN). It is the responsability of the PI at 
each Center to keep a logbook to maintain the link of patient ID and the code. No identifiers will 
be included in the database. Data entry will be performed via web. Access will be regulated by a 
center username and account. Each Center will be able to see and modify its own records only. 
The study PI will be able to see all records. Export of the database will be allowed to the study 
statistician. 
5.2. Handling of missing data and drop-outs 
NA 

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6 
REGULATORY ASPECTS AND SAFETY 
6.1 Local regulations / Declaration of Helsinki 
This study is conducted in compliance with the protocol, the current version of the Declaration of 
Helsinki, the ICH-GCP, the HRA as well as other locally relevant legal and regulatory 
requirements.  
6.2 (Serious) Adverse Events- 
An Adverse Event (AE) is any untoward medical occurrence in a patient or a clinical investigation 
subject which does not necessarily have a causal relationship with the trial procedure. An AE can 
therefore be any unfavourable or unintended finding, symptom, or disease temporally associated 
with a trial procedure, whether or not related to it. 
 
A Serious Adverse Event (SAE) (ClinO, Art. 63) is any untoward medical occurrence that 
- 
Results in death or is life-threatening, 
- 
Requires in-patient hospitalisation or prolongation of existing hospitalisation, 
- 
Results in persistent or significant disability or incapacity, or 
- 
Causes a congenital anomaly or birth defect  
 
Both Investigator and Sponsor-Investigator make a causality assessment of the event to the trial 
invervention, (see table below based on the terms given in ICH E2A guidelines). Any event 
assessed as possibly, probably or definitely related is classified as related to the trial intervention. 
 
Relationship 
Description 
Definitely 
Temporal relationship 
Improvement after dechallenge* 
Recurrence after rechallenge 
(or other proof of drug cause) 
Probably 
Temporal relationship 
Improvement after dechallenge 
No other cause evident 
Possibly 
Temporal relationship 
Other cause possible 
Unlikely 
Any assessable reaction that does not fulfil the above conditions 
Not related 
Causal relationship can be ruled out 
*Improvement after dechallenge only taken into consideration, if applicable to reaction 
Both Investigator and Sponsor-Investigator make a severity assessment of the event as mild, 
moderate or severe. Mild means the complication is tolerable, moderate means it interferes with 
daily activities and severe means it renders daily activities impossible.  
 
Reporting of SAEs (see ClinO, Art. 63) 
All SAEs are documented and reported immediately (within a maximum of 24 hours) to the 
Sponsor-Investigator of the study. 
All reported SAEs, independently from their classification, will be recorded in the eCRF by filling 
in the “adverse event” section. 
If it cannot be excluded that the SAE occurring in Switzerland is attributable to the intervention 
under investigation, the Investigator reports it to the Ethics Committee via BASEC within 15 days. 

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If the SAE occurs at one of the study sites, the coordinating Investigator reports the events to the 
Ethics Committee concerned, within 15 days. 
 
Follow up of (Serious) Adverse Events 
In case participants terminating the study (either regularly or prematurely) with reported ongoing 
SAE, or any ongoing AEs of laboratory values or of vital signs, the patient will be followed by the 
cardiologist or the specialist.  
All AEs will be followed in order to elucidate as completely and practical as possible their nature 
and/or causality. The follow-up information will be submitted until resolution of all queries, clinical 
recovery is complete, laboratory results have returned to normal, until progression has been 
stabilized or till the conditions are considered out of threaten and acceptable or until the patient 
is lost to follow-up. Follow-up may therefore continue until after the patient has left the 
investigation. 
Notwithstanding, any SAE will be followed-up after the study end until resolution or stabilization 
or till patient’s health is considered no more at risk at Investigator’s discretion. 
In case of death, a comprehensive narrative report of the case should be prepared by the 
Investigator and sent to the Sponsor Safety Contact by fax together with the SAE form, retaining 
a copy on site with the CRF. Any efforts should be performed in order to contextualize the 
circumstances leading to fatal outcome. 
 
6.3 (Periodic) safety reporting 
An annual safety report (ASR/DSUR) is submitted once a year to the Swiss Ethics Committee by 
the Investigator (ClinO, Art. 43 Abs). 
In international multicentric studies the ASR/DSUR contains information from all sites including 
information from sites outside of Switzerland. The Sponsor-Investigator distributes the 
ASR/DSUR to all the participating Investigators. 
6.4 Radiation 
No extra radiation is administered to patients during this study. Patients will receive standard of 
care treatment for breast cancer. 
6.5 Pregnancy  
Pregnancy in an exclusion criterion. 
6.6 Amendments 
Substantial changes to the study setup and study organization, the protocol and relevant study 
documents are submitted to the Ethics Committee for approval before implementation. Under 
emergency circumstances, deviations from the protocol to protect the rights, safety and well-being 
of human subjects may proceed without prior approval of the Ethics Committee. Such deviations 
shall be documented and reported to the Ethics Committee as soon as possible. 
Substantial amendments are changes that affect the safety, health, rights and obligations of 
participants, changes in the protocol that affect study objective(s) or central research topic, 
changes of study site(s) or of study leader and sponsor (ClinO, Art. 29). 
A list of substantial changes is also available on www.swissethics.ch. 
A list of all non-substantial amendements will be submitted once a year to the competent EC 
together with the ASR. 

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6.7 (Premature) termination of study 
The Sponsor-Investigator may terminate the study prematurely according to certain 
circumstances, e.g. 
- 
Ethical concerns, 
- 
Insufficient participant recruitment, 
- 
When the safety of the participants is doubtful or at risk (e.g. when the benefit-risk 
assessment is no longer positive), 
- 
Alterations in accepted clinical practice that make the continuation of the study unwise, or 
- 
Early evidence of harm or benefit of the experimental intervention 
 
Upon regular study termination, the Ethics Committee is notified via BASEC within 90 days (ClinO, 
Art. 38).  
Upon premature study termination or study interruption, the Ethics Committee is notified via 
BASEC within 15 days (ClinO, Art. 38). 
Health-related data are anonymised upon end of data analysis. 
6.8 Insurance 
An Insurance policy has been undersigned to cover subjects who enter the trial. 
 
FURTHER ASPECTS 
7.1 Overall ethical considerations 
To our knowledge, our proposed study is the first longitudinal prospective one which includes 
150-200 patients. Its primary endpoint is to evalute myocardial oedema on CMR after cardiotoxic 
systemic and radiation therapy in predicting the incidence of cardiotoxicity. It is important to 
distinguish these high risk patients who need intensive cardiovascular screening during and after 
cardiotoxic treatment. Our purpose is find these risk group patients when the toxicity is still 
subclinical and reversible and prevent the subclinical toxicity with protective drugs administered 
to the right patient at the right time. 
7.2 Risk-benefit assessment  
Patients are treated according to current best practice and International Guidelines. Based on the 
assumptions of the study and the sponsor's previous clinical experience as well as current 
scientific knowledge, it is possible that by participating in the study patients benefit from a 
diagnostic evaluation with CMR. Our aim is to diagnose a possible event when it is still subclinical 
and reversible and to prevent its evolution with protective drugs. Distinguish asymptomatic 
patients who are at risk of cardiotoxicity and, if possible, avoid side effects with protective 
treatment. This study does not involve any risks to patients. 
8 
QUALITY CONTROL AND DATA PROTECTION 
8.1 Quality measures  
For quality assurance the sponsor, the Ethics Committee or an independent trial monitor may visit 
the research sites. Direct access to the source data and all study related files is granted on such 
occasions. All involved parties keep the participant data strictly confidential.  

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8.2 Data recording and source data 
Data will be collected in a dedicated database in Filemaker 11. The database will be resident on 
a Server at CCT. Backup will be performed according to the local operating procedures. Data will 
be pseudoanonymized with a unique personal number (UPN). It is the responsability of the PI at 
each Center to keep a logbook to maintain the link of patient iD and the code. No identifiers will 
be included in the database. Data entry will be performed via web. Access will be regulated by a 
center username and account. Each Center will be able to see and modify its own records only. 
The study PI will be able to see all records. Export of the database will be allowed to the study 
statistician. 
8.3 Confidentiality and coding 
Trial and participant data will be handled with uttermost discretion and is only accessible to 
authorised personnel who require the data to fulfil their duties within the scope of the study. On 
the CRFs and other study specific documents, participants are only identified by a unique 
participant number.  
8.4 Retention and destruction of study data and biological material 
All study data are archived for 10 years after study termination or premature termination of the 
study. 
9  MONITORING AND REGISTRATION 
Radiation Oncology Clinic is responsible of monitoring and registration in a national language in 
the Swiss National Clinical trial Portal (SNCTP via BASEC)  
The study, after approval, will be registered in a registry listed in the WHO International Clinical 
Trials Registry Platform (ICTRP; http://www.who.int/ictrp/en/), if it satisfies the definition given 
therein.  
10. FUNDING / PUBLICATION / DECLARATION OF INTEREST 
Funding has not appointed for this study. 
The data collected during the study will be the property of the Investigators.  
Results of the present study will not be disseminated or published until the study data are mature 
for the final analysis of the primary study endpoint. An interim-analysis could be performed when 
50% of patients have been enrolled and have completed the 6 months follow-up. 
This study is intended for publication irrespective of its results. The final publication of the main 
trial results will be written by Study Coordinators on the basis of the final analysis report. It will be 
published in a peer-reviewed scientific journal within 1.5 year of the end of the study.  
The publications must conform to the CONSORT guidelines and to the International Committee 
of Medical Journal Editors guidelines on authorship.  
Authorship is decided in accordance with the recommendations of the International Committee of 
Medical 
Journal 
Editors 
defining 
the 
roles 
of 
authors 
and 
contributors 
(http://icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-
authors-and-contributors.html).  
The first and last authors of publication of primary study results are the Study Coordinators who 
initiated the study design. Other Study Coordinators are usually second, third or fourth author. 
Specialists responsible for the collection and analysis of patient reported outcomes also qualify 
as co-author.  
For publication of ancillary studies, the first author is the coordinator of the corresponding 
research, co-authors will include the study coordinators and scientific collaborators who made 

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substantial contribution to the research.  
Other investigators and scientific contributors to the publication who do not qualify for authorship 
will be acknowledged in the publication. 
Revision of posters, abstracts or any other kind of publication should be carried out within 15 
days. 
10 REFERENCES 
1) Waks AG, Winer EP, Breast Cancer Treatment: A Review. JAMA. 2019 Jan 
22;321(3):288-300 
2) Barish, R, Lynce F, Unger K, Barac A, Management of Cardiovascular Disease in Women 
With Breast Cancer, Circulation. 2019 Feb 19;139(8):1110-1120 
3) Cardinale D, Ciceri F, Latini R, et al. Anthracycline-induced cardiotoxicity: A multicenter 
randomised trial comparing two strategies for guiding prevention with enalapril: The 
International CardioOncology Society-one trial. Eur J Cancer. 2018 May;94:126-137 
4) Zamorano JL, Lancellotti P, et al. 2016 ESC Position Paper on cancer treatments and 
cardiovascular toxicity developed under the auspices of the ESC Committee for Practice 
Guidelines:  The Task Force for cancer treatments and cardiovascular toxicity of the 
European Society of Cardiology (ESC). European Heart Journal, Volume 37, Issue 36, 21 
September 2016, Pages 2768–2801 
5) Curigliano G, Cardinale D, Dent S, et al. Cardiotoxicity of Anticancer Treatments: 
Epidemiology, Detection, and Management. CA Cancer J Clin 2016;66:309-325 
6) Cardinale D, Colombo A, Bacchiani G, et al. Early detection of anthracycline cardiotoxicity 
and improvement with heart failure therapy. Circulation. 2015 Jun 2;131(22):1981-8 
7) Cahlon O, Khan AJ. Cardiac Toxicity: The More We Learn, the Less We Know. Int J Radiat 
Oncol Biol Phys. 2017 Dec 1;99(5):1162-1165 
8) Jaworski C, Mariani JA, et al .Cardiac Complications of Thoracic Irradiation. J Am Coll 
Cardiol. 2013 Jun 11;61(23):2319-28 
9) Zagar TM; Cardinale DM, Marks LB. Breast cancer therapy-associated cardiovascular 
disease. Nat Rev Clin Oncol. 2016 Mar;13(3):172-84 
10) Ridker PM, Hennekes CH, Buring JE, Rifai N. C-reactive protein and other markers of 
inflammation in the prediction of cardiovascular disease in women. N Engl J Med. 2000 
Mar 23;342(12):836-43. 
11) Ridker PM, Danielson E, Fonseca FAH, et al. Rosuvastatin to Prevent Vascular Events in 
Men and Women with Elevated C-Reactive Protein. N Engl J Med 2008; 359:2195-2207 
12) Ridker PM, MacFadyen JG, Everett BM, et al. Relationship of C-reactive protein reduction 
to cardiovascular event reduction following treatment with canakinumab: a secondary 
analysis from the CANTOS randomised controlled trial. Lancet. 2018 Jan 
27;391(10118):319-328. 
13) Ontilo AA, Stankowski RV, Berg RL. High-sensitivity C-reactive protein (hs-CRP) as a 
biomarker for trastuzumab-induced cardiotoxicity in HER2-positive early-stage breast 
cancer: a pilot study. Breast Cancer Res Treat (2012) 134:291-298 
14) Galderisi M, Lancellotti P. What is the best imaging tool in cardio-oncology? E-Journal of 
Cardiology Practice. 2019 Feb, Vol 16, N 39. 
15) Charbonnel C, Convers-Domart R, Rigaudeau S, et al. Assessment of global longitudinal 
strain at low-dose anthracycline-based chemotherapy for the prediction of subsequent 
cardiotoxicity. Eur Heart J Cardiovasc Imaging. 2017 Apr 1;18(4):392-401 
16) Farhad H, Staziaki PV, Addison D, et al. Characterization of the Changes in Cardiac 
Structure and Function in Mice Treated With Anthracyclines Using serial Cardiac Magnetic 
Resonance Imaging. Circ Cardiovasc Imaging. 2016 Dec;9(12). 
17) Galán-Arriola C, Lobo M, Vílchez-Tschischke JP, et al. Serial Magnetic Resonance 
Imaging to Identify Early Stages of Anthracycline-Induced Cardiotoxicity. J Am Coll 
Cardiol. 2019 Feb 26;73(7):779-791 

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18) Jordan JH, D’Agostino Jr RB, Hamilton CA, et al. Longitudinal Assessment of Concurrent 
Changes in Left Ventricular Ejection Fraction and Left Ventricular Myocardial Tissue 
Characteristics After Administration of Cardiotoxic Chemotherapies Using T1-Weighted 
and T2-Weighted Cardiovascular Magnetic Resonance. Circ Cardiovasc Imaging. 2014 
Nov;7(6):872-9 
19) EBCTCG Peto R, Davies C, et al. Comparisons between different polychemotherapy 
regimens for early breast cancer: meta-analyses of long-term outcome among 100,000 
women in 123 randomised trials. Lancet. 2012 Feb 4;379(9814):432-44 
20) Sari SY, Yazici G, Sendur MA, et al. Concurrent Trastuzumab Use With Radiation Therapy 
and the Risk for Cardiotoxicity. Int J Radiat Oncol Biol Phys. 2016 Oct 1;96(2):E10-E11 
21) Darby SC, Ewertz M, McGale P, et al. Risk of Ischemic Heart Disease in Women after 
Radiotherapy for Breast Cancer. N Engl J Med 2013;368:987-98. 
22) Meyersohn NM, Pursnani A, Neilan TG. Detection of Cardiac Toxicity Due to Cancer 
Treatment: Role of Cardiac MRI. Curr Treat Options Cardio Med (2015) 17: 38. 
23) Common 
Terminology 
Criteria 
for 
Adverse 
Events 
(CTCAE) 
https://www.eortc.be/services/doc/ctc/CTCAE_4.03_2010-06-
14_QuickReference_5x7.pdf 
24) Declaration 
of 
Helsinki 
https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-
medical-research-involving-human-subjects/ 
25) Federal 
Act 
on 
Data 
Protection 
(FADP) 
https://www.admin.ch/opc/en/classified-compilation/19920153/index.html 
26) Human 
Research 
Act 
(HRA) 
https://www.admin.ch/opc/de/classified-compilation/20061313/index.html 
27) International Conference on Harmonization (ICH) E6(R2) Guideline for Good Clinical 
Practice 
http://www.ich.org/fileadmin/Public_Web_Site/ICH_Products/Guidelines/Efficacy/E6/E6_
R2__Step_4_2016_1109.pdf 
28) International Conference on Harmonization (ICH) E2A Clinical Safety Data Management: 
Definitions 
and 
Standards 
for 
Expedited 
Reporting 
http://www.ema.europa.eu/docs/en_GB/document_library/Scientific_guideline/2009/09/
WC500002749.pdf 
29) Ordinance 
on 
Clinical 
Trials 
in 
Human 
Research 
(ClinO) 
https://www.admin.ch/opc/de/classified-compilation/20121176/index.html 
 
 
 
 
 

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Appendix 1 
Schedule of assessments 
 
 
 
 
 
 

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Appendix 2 
Ancillary Study 
 
An Ancillary study will be performed at Istituto Oncologico della Svizzera Italiana (IOSI), 
Bellinzona (CH) and North Estonia Medical Center, Tallinn (EST). 
The study population consists of stage 0 breast cancer patients who will be treated with surgery, 
adjuvant radiation therapy +/- hormonal therapy. 
 
Primary endpoint:  
To assess the role of myocardial oedema on CMR (T2 mapping) after radiation therapy in 
predicting the incidence of cardiotoxicity, defined as by consensus guidelines* (decline of LVEF 
≥10% points with a final LVEF <53%) measured on CMR and ECHO over the time window of 12 
months from the end of radiation therapy.  
*American Society of Echocardiography and European Association of Cardiovascular Imaging 
Expert Consensus 
 
Secondary objectives: 
1. 
To detect GLS decrease >15% from baseline, measured on Echo over the time 
window of 12 months 
2. 
To see if the changes in biomarkers will correlate with LVEF measurements, assessed 
by ECHO and CMR 
3. 
To see if the changes in biomarkers will correlate with GLS measurements, assessed 
by ECHO  
4. 
To compare the time to the biomarkers positivity to the time to the decrase in GLS 
>15% and/or decline of LVEF ≥10% points with a final LVEF <53% measured on Echo.    
5. 
To find out if patients with increased baseline biomarkers will develop cardiotoxicity; 
identify predictors of cardiotoxicity by multivariable analysis 
6. 
To detect major cardiovascular events (defined as acute myocardial infarction, 
hospitalization due to heart failure, atrial flutter/fibrillation, ventricular tachycardia) or 
death due cardiac problems during the follow up 
7. 
To assess the role of fibrosis on CMR (T1 mapping with evaluation of extracellular 
volume) after cardiotoxic systemic therapy and/or radiation therapy in predicting the 
incidence of cardiotoxicity. 
8. 
To detect incidence of acute asymptomatic pericarditis after radiation therapy, 
measured on CMR  
9. 
To investigate if the area of the edema on CRM correlates with RT dose distribution 
10. 
To assess the incidence of myocardial oedema on CMR (T2 mapping) after radiation 
therapy and cardiotoxic systemic therapy measured on CMR and ECHO over the time 
window of 12 months from the end of radiation therapy. 
 
Inclusion criteria: 
Patients eligible for inclusion in this study must fulfill all of the following criteria: 
1. 
Written informed consent must be obtained before any assessment is performed 
2. 
Female, age ≥ 18 years at visit 1 
3. 
Performance status ECOG 0-1 
4. 
Stage 0-II histology proven breast cancer 
5. 
Treated with operation, adjuvant radiation therapy +/- hormonal therapy 
6. 
Negative pregnancy test (plasma HCG) for all females of childbearing potential (i.e 
not permanently sterilised- post hysterectomy or tubal ligation status) 
 
Patients will be excluded if they meet any of the following criteria:  

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1. 
Known metastatic spread of any cancer 
2. 
Breast cancer patients treated with chemo/immunotherapy 
3. 
Known active or recurrent hepatic disorder (cirrhosis, hepatitis), ASAT/ALAT 2xULN 
4. 
Renal function decrease (eGFR < 30 ml/min) 
5. 
Known coronary artery disease 
6. 
Positive or missing pregnancy test (pre- and perimenopausal women) at enrolment 
visit 
7. 
Patients with baseline LVEF <53% and GLS <15% 
8. 
Patients with pacemaker 
 
Patients in this ancillary study will follow the procedures of the main study. 
A signed consent will be obtained from every participant in the ancillary study. 
 
 
 
 
Appendix 3 
Technical aspects of radiation therapy 
 
A) IOSI 
1. Tumori della mammella 
1.1. CTV Mammario (CTV II) 
Il disegno del CTV II si basa sulle seguenti informazioni: 
 
limiti palpabili del corpo mammario identificati con reperi radio-opachi 
 
anatomia TC della ghiandola mammaria (tenendo conto che il tessuto ghiandolare 
visibile su TC può non corrispondere esattamente alla sua reale estensione) 
 
anatomia TC di strutture anatomiche extramammarie di riferimento. 
 
Il CTV II è costituito dall’intera mammella, fino a 0,3-0,5 cm al di sotto della superficie 
cutanea. 
L’espansione a PTV II deve tener conto delle escursioni respiratorie e delle incertezze 
di posizionamento. Espansione 0,7-1 cm, “crop” dalla cute 0,3-0,5 cm. 
 
3.1.1 Dosi e frazionamenti 
Dopo chirurgia conservativa la mammella può essere trattata impiegando un 
frazionamento convenzionale,1.8-2 Gy/die in 5 frazioni settimanali fino alla dose 
totale di 50-50.4 Gy, o schemi ipofrazionati, con la stessa equivalenza in termini 
di efficacia e tossicità.  
 
1.2. Boost (CTV I) 
La presenza di clips nel letto operatorio permette una migliore definizione dell’area da 
irradiare. 
Il volume bersaglio (PTV I) del boost deve comprendere:  
 
il letto operatorio (CTVI) con 1,5 cm di margine se l’escissione è completa 
 
il letto operatorio (CTVI) con 3 cm di margine se l’escissione è incompleta e non si 
prevede un re-intervento. 
 
L’espansione a PTV I deve tener conto delle escursioni respiratorie e delle incertezze 
di posizionamento. Espansione 0,7-1 cm, crop dalla cute 0,3-0,5 cm. 
 
3.2.1 Dosi e frazionamento 

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Di norma sono previste, in caso di margini di resezione istologicamente negativi, 
dosi totali al letto operatorio di 10-16 Gy in 5-8 frazioni (2 Gy/die).  
 
1.3. CTV Parete toracica (dopo mastectomia) 
Il disegno del CTV si basa sulle seguenti informazioni:  
 
limiti anatomici della parete toracica identificati con reperi radio-opachi, incluso 
repere sulla cicatrice di mastectomia 
 
anatomia TC della parete toracica 
 
anatomia TC di strutture anatomiche extramammarie di riferimento. 
 
L’espansione a PTV deve tener conto delle escursioni respiratorie e delle incertezze di 
posizionamento. Espansione 0,7-1 cm, “crop” dalla cute 0,3-0,5 cm se T1-T3.  
Nel caso di T4, la cute sarà compresa nel CTV e PTV e dovrà essere previsto un bolus 
(spessore 0,5-1 cm) per ottimizzare la distribuzione di dose. 
3.3.1 Dosi e frazionamento 
Dopo mastectomia la parete toracica può essere trattata impiegando un 
frazionamento convenzionale, 2 Gy/die in 5 frazioni settimanali fino alla dose 
totale di 50 Gy +/- boost su cicatrice chirurgica se indicato.  
 
1.4. CTV/PTV Stazioni linfonodali di I drenaggio 
Regione sovraclaveare, catena mammaria interna, ascella omolaterali. 
La decisione di irradiare le stazioni linfonodali dipende dallo stadio di malattia, dal 
numero di linfonodi metastatici e dalle caratteristiche immuno-istochimiche del tumore. 
 
3.4.1 Dosi e frazionamento 
Dopo chirurgia conservativa o mastectomia le aree linfonodali possono essere 
trattate impiegando un frazionamento convenzionale,1.8-2 Gy/die in 5 frazioni 
settimanali fino alla dose totale di 50-50.4 Gy.  
 
1.5. Organi a rischio 
 
mammella controlaterale 
 
cuore 
 
polmone omolaterale 
 
Arteria Coronarica Discendente Anteriore (LAD) 
 
tiroide 
 
midollo spinale 
 
plesso brachiale 
 
 
Dose constraints for breast/chest wall +/- lymph nodes (IM,SC,Axilla) target volumes and 
organs at risk: 
 
Cuore 
V5Gy ≤ 40.0% (≤ 50.0% for left-sided tumors) 
V20Gy ≤ 20.0% 
QUANTEC 25Gy (V25) <10%  
Polmone omolaterale  
V20Gy<25% solo breast 
V20Gy<35% breast + lymph nodes 
Mean <18Gy 
Polmoni  
Mean 20Gy  
V20Gy ≤ 25.0% 
V30Gy ≤ 20.0% 

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Mammella controlaterale  
V5Gy ≤ 15.0% 
Midollo 
Max 45/47/50/50.5Gy 
0.03cc<48Gy 
LAD 
V20Gy = 0% 
Tiroide (se RT su sola mammella) 
Tiroide (se RT su SC) 
V26Gy<20% 
Accettare 50 Gy su lobo omolaterale 
Plesso brachiale 
Max 50Gy 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Appendix 5  
ECHO and CMR measured parameters and protocol 
 
On ECHO the following parameters will be defined: 
• Left ventricular (LV) End Diastolic and Systolic diameter (mm)  
• Septal and Posterior Wall Thickness (mm)  
• 2D with or without 3D LV end diastolic and systolic volume index (LV EDVi, LV ESVi, mL/m2)  
• 2D with or without 3D LV ejection fraction (LV EF, %)  
• LV Global longitudinal strain (GLS, %)  
• Left atrial volume (ml/m2)  
• Mitral Valve (MV) E/A ratio, MV Deceleration Time (DT, ms)  
• Pulsed-wave TDI e’ velocity (cm/s), Mitral E/e’  
• Pulmonary vein’s flow  
• Aortic root and annulus diameters (mm)  
• Right ventricular (RV) diameter (mm), TAPSE (mm)  
• RV fractional area change (%)  
• Tricuspid regurgitation (TR) and Systolic pulmonary artery pressure (SPAP, mmHg)  
• Valvular apparatus  
• Inferior Vena Cava (IVC) diameter (mm) and Collapsibility 
 
CMR will be performed as above: All patients will undergo a standard protocol, including late 
gadolinium enhancement for eGFR >30 ml/min. For native T1 and post-contrast mapping, basal, 
midventricular, apical short-axis and 4-chamber long-axis images will be acquired by “ECG 
triggered the modified Look-Locker inversion recovery” (MOLLI) sequence. Additionally, T2 
mapping (T2-prepared Treu-FISP) will be acquired on the same plane. At the time of insertion of 
the iv cannula, blood will be drawn for hematocrit measurement. All CMR images and maps will 
be analyzed offline. Late gadolinium enhancement (LGE) will be quantified on short-axis stacks 
using a semiautomatic approach. 
 
 
 
 
Appendix 6  
DOCUMENTO INFORMATIVO SULLO STUDIO 
 
 
Appendix 7 
Consent form