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    11 views10 pages

    Mama PDF

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    Antonio Robson

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    © All Rights Reserved
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    Breast IMRT aaa eat Contents 71 TheClinical Problem - 7.11 Isolated Breast Treatment» Bt 7.12 Loco-Regional Breast(Chest Wall Treatment 7.13 Simultaneous Integrated Boost (IB) . » -- 72 Unique Anatomical Challenges. - er 721 Lungand Heart Avoidance «6.2.2... 722 Imer-and Intra-Fraction Motion... 22. 2 374 am 3 74 2S Clinical Experience 754 Isolated Breast IMRT ae 782. Loco-Regional Breast{Chest Wall IMRT. 76 Future Directions(Conclusion . . References... + bee vo 300 7.1 The Clinical Problem wolved in the management of breast cancer patients throughout the spectrum of the disease: from adjuvant treatment of early and locally advanced stage to palliative treatment of metastasis. In the adjuvant setting there are two distinct clinical s ations; (1) treatment of the breast only following breast conserving surgery for early stage disease and (2) treat- ment to the breast/chest wall and regional nodes for locally advanced disease. The use of radiotherapy in these clinical settings has been shown to improve local, local-regional control and overall survival [1-4]. When \diotherapy was first introduced into these clinical set- is, broad field designs were used. These original broad fields were simplistic in design, and limited by the planning and treatment delivery systems available. However, because oftheir simplicity, successin reducing disease recurrence, and ease of implementation, these ‘treatment techniques quickly became widely adopted. In fact, the majority of treatment centers today continue the Chapter same general disease management principles and treat- ‘ment approaches originally designed and practiced in the 1970s and 1980s. Although upgraded field matching techniques and CT based treatment planning have been incorporated in many centers, minimal modifications havebeen made until recently with the emergence of im- age based treatment planning and advanced, intensity modulated radiotherapy delivery techniques. Intensity Modulated Radiotherapy (IMRT) in the treatment of breast cancer offers improved dose conformality and homogeneity. Only through appropriate investigation ll we be able to determine whether this improvement dose delivery actually translates into a clinical ben- efit and, therefore, justify widespread adoption of this treatment technology. 7.1.1 Isolated Breast Treatment Treatment of the whole breast following lumpectomy to achieve in-breast disease control has been documented tobe successful in both local control and cosmetic out- come [1,2,5]. The use of parallel opposed tangential fields, with varying levels of mechanical compensa- tion, has become the standard whole-breast treatment approach due to its straight-forward simplicity, and fa ity of use from large randomized trials. The need for improvements in thesesimple but effective treatment approaches has been challenged and, therefore itis ap- propriate to evaluate whatimprovements can be realized with IMRT [6-8]. Aslocal control rates are primarily de- pendent on appropriate surgical resection followed by modest doses of adjuvant radiotherapy, improved dose coverage of the breast target or dose escalation for tu- mor control may not be necessary. Ithas been suggested that the application of IMRT forces physicians to fo- cus attention on target delineation and target coverage therefore possibly yielding an improvement in disease control [9]. However, this advantage would not be a re- sult of treatment delivered with IMRT technology but rather a result of the target-focused planning process which can also be achieved through appropriate applica- tion of conventional treatment techniques. The potential 372 1. Clinical advantages that IMRT technique may have over conven- tional 3D and non-3D techniques are (1) the ability to achieve dose uniformity throughout the breast target and (2) the potential to reduce the dose to underlying heart and lung. These abilities are expected to trans- late into an improved cosmetic outcome and reduced toxicity. “Although itis recognized that, in many women, ap- propriate use of mechanical wedges produces acceptable homogeneity, management of moist desquamation is the inframammary fold and low axilla is often nec- essary and late breast fibrosis (inframammary fold fibrosis), breast edema and costochondral discomfort are frequently encountered. Possibly due to the ease of standard tangential treatment, the successful local con- trol rates and the significant improvement of life quality over mastectomy, these toxicities have been accepted as a part of the standard of care, Initially, it was com- ‘mon to follow the treatment guidelines used in NSABP B-06, where uncompensated tangential fields (i.e, no wedge filters used) were prescribed to midplane at a point two-thirds the distance from the skin to the base of the tangent at central axis [10]. As a result, the ante- rior aspect ofthe treated breast received a daily dose and total dase that exceeded the prescription dose, masking the fact that doses higher than 50Gy to the surgical bed were often delivered. The degree of this inhomo- geneity would have been variable as it is dependent on the size and shape of the breast. Im the absence of dosimetric information, the effect is dificult to quan- titate, Recognizing the varying level of inhomogeneity with such an approach, wedge filters have since been universally adopted to compensate for the difference in breast width encountered, However, wedges do not compensate for three-dimensional changes and toxic- ity related to dose inhomogeneity is still encountered. Mechanical lead compensators have been described as, a method of providing customized compensation that achieves a highly homogeneous dose distribution [11] ‘This approach has been adopted in some centers but has never achieved widespread use as planning, compen- sator construction and treatment delivery times have been viewed as excessive, despite dosimetric benefits The emergence of IMRT and multi-leaf collimation has provided an electronicmethod of 3D compensation that addresses these difficulties by providing an automated method of delivering a homogeneous dose. For this and other reasons, IMRT’ has the potential to become the preferred method of radiation delivery for breast cancer, In the treatment of breast-only, IMRT is unlikely to make a great improvement in the already-low normal tissue complication probability. In whatever manner the breast target is defined, it remains a concave structure with lung and, if let sided, heart tissue directly adja cent. Avoiding dose to the underlying lung and heart has been the goal of some IMRT techniques; however, the dose reductions are marginal and of questionable

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