Accelerated Partial Breast Irradiation

ADVANTAGES :

 Improved patient convenience and acceptability

 Reduced treatment time, treatment cost, volume of normal tissue exposed to radiation(lung,
heart) and radiation toxicity
 Treatment focused to area of highest risk of residual occult disease/recurrence.
METHODS:

a) Interstitial brachytherapy
b) TARGIT
c) ELIOT
d) Mammosite
e) 3DCRT
f) IMRT

Interstitial Brachytherapy
 Oldest method
 Large and encouraging data
 Good target volume coverage with sparing of normal tissues
 Brachytherapy Machines more common .

 Requires technical expertise.

 Most commonly used method

 Post op interstitial brachytherapy within 8 weeks of primary surgery

 Dose- HDR dose-34Gy/10#/5days

Factor Suitable group Cautionary Unsuitable
Patient ≥60years 50-59 Age <50
Factors Age years

Pathologic factors
Tumor size ≤2cm 2.1-3 >3cm
T stage T1 T0, T2 T3,T4
Margins Negative (> 2 Close Positive
mm) (<2mm)
Grade Any
LVSI No Limited/focal Present
extensive
ER status Positive Negative
Multicentricity Unicentric only Present
Multifocality Unifocal >3cm
Histology Invasive Invasive >3cm
Pure ductal ,favo lobular >3cm
DCIS rable Not ≤3cm
EIC allowed ≤3cm
Not alowed
Nodal pNo PN1, N2, N3
factors N SN Bx or ALND
stage
Nodal
surgery
Treatment Not allowed Used
factors
Neoadjuvant
therapy
METHODS OF APPLICATION

 Template guided
 Single/double/three plane.

PROCEDURE:
• Needles are implanted parallel and equidistance from each other(Paris system)
• In most cases inserted in mediolateral direction
• In very medially or laterally located tumor sites, needles should be implanted in
craniocaudal direction to enable separate target area from skin points
• In some rare cases, upper outer quadrant has to be implanted with needle oriented in
45 degree angle to avoid overlap of source position and skin
• Single plane <12mm
• 2 planes of needles are usually needed to cover the PTV
• 3 planes are required in a large breast where the targeted breast tissue between
pectoral fascia and skin is thicker than 30mm
• 5-9 needles spaced 15-20mm are usually required
 • If superficial needles are too close to the skin, the templates are moved toward each
other so that overlying skin moves up and away from the needles
• If not sufficient, templates with smaller spacing between the needles are used,
resulting in compression of breast tissue and upward movement of skin
• Gauze is used between the templates and skin of thoracic wall at both sides of implant
to avoid skin necrosis secondary to continuous pressure of template
Advantages:
• Longest follow up.
• Better control and tailoring of radiation dose delivery to variation in lumpectomy
cavity, shape, location of breast.
• Limit toxicity to healthy tissue while delivering the maximum dose to at risk tissue.
GEC-ESTRO Randomized trial of APBI

Stage 0,I and II

Low risk and invasive breast carcinoma Treated with breast conserving therapy

Whole Breast RT + Tumor bed boost 50Gy Interstitial Multicatheter

+10Gy Brachytherapy HDR:32Gy/8#
WBRT APBI P va
PDR: 50Gy in pulses of0.6-
5 year Local Recurrence 0.97% 1.38% 0.53
0.8Gy/hr given hourly

5 year disease free 94.45% 95.03% 0.79

survival

5 year overall survival 95.5% 97.25% 0.11

Limitations:
• Considerable training and experiences
• Dose inhomogenity
• High skin dose
Thus not be viable treatment option for patients with superficial tumor or small breast
Complications:-
• Port site infection
• Abscess
• Bleeding
• Breast fibrosis
NSABP-B39/RTOG 0413:PBI OR WBI IN STAGE 0.I.II.BC
PBI was given 3.4-3.85Gy twice daily either with brachytherapy or 3DCRT. Noabsolute
difference in 10year rate of IBTR .
INTRACAVITARY BRACHYTHERAPY

Mammosite

• Balloon with single catheter

• Dose: 34Gy/10 fraction BID Advantage:
• Ease of application
• Problems:
 High skin dose and telengectesia Rib fractures
 Problem in non-uniform cavities
It is a dual-lumen spherical balloon catheter infl atable to 4–5 cm with a central lumen for the high
dose rate (HDR) iridium-192 (192Ir) source. The catheter is a silicone balloon and shaft
approximately 6 mm in diameter and 15 cm in length . The shaft contains a small infl ation channel
and a larger central “treatment” channel for passage of the HDR source

Criteria for patient selection

• T1,<2cm,N0,M0
• Edges of post surgical cavity must be more than 5-7mm from skin surface
• Cavity size >3 cm
• Negative surgical margin

INELIGIBLE:
• An extensive intraductal component
• pure intraductal cancers
• lobular histology
• collagen vascular disease
PROCEDURE
• After lumpectomy ,catheter is placed in breast cavity either during lumpectomy
procedure or later through closed technique
• Balloon is inflated with 35 to 70 ml of saline mixed with small amount of contrast
material, depending on size of lumpectomy cavity
• CT imaging to assess the adequate placement of the devices
• An Ir-192 radioactive source connected to computer controlled HDR remote after-
loader, is inserted through catheter into balloon to deliver the prescription radiation
dose
• Minimum balloon to skin distance for good cosmesis
• 5-7mm is required
• Symmetry is essential for adequate dosimetry
• A non symmetrical implant result in dose in homogeneity to surrounding tissue
• Dose - 34Gy over 10 #(@3.4 Gy/ fraction, twice daily)
• Prescription point is 1 cm from balloon surface
• Minimum 6 hours gap.

Advantages:

• Easily reproducible
• More user friendly technique for brachytherapy.

Disadvantage:
 • Inadequate skin sparing due to poor spacing
• Infection(16%)
• Recurrent seroma
• Balloon rupture

Mutli-channel Catheters

• Mutlichannel Balloon based brachytherapy

• Single balloon: to be inflated

• Coverage better than Mammosite
• Issues related to cavity coverage in irregularly shaped cavities

Intraoperative X rays
Targeted intraoperative therapy

Source: 50KV Xray source

Technique: Intraoperative radiation after wide excision

Dose: 20Gy in 1 fraction at 1mm Effective dose at 1cm: 5-7Gy
Advantage:

 simple technique
 sparing of normal tissues Problems:
 Issues of penetration
 Adequacy of cavity wall dose
 Encouraging early results
TARGIT trial

• Age > 45 years, T size upto 3 cm, unifocal tumors

• BCT+TARGIT vs BCT+ External RT
• Local recurrence rate at 4 years TARGIT group: 1.2%
• External RT group: 0.95%

5year outcome: Local Recurrence in TARGIT arm: 3.3%

Local recurrence in EBRT arm: 1.1%

 • TARGIT inferior to EBRT for Local Control

Intra-operative Electrons:

• Machine: Mobile linear accelerator

• Electron energy: 3-10MeV Technique: Wide excision
• Placement of shield to protect chest wall Reconstruction of the tumor bed
• Dose: 21Gy at 90% isodose Advantages: single fraction
• Problems: Issues of cavity wall coverage .
• Set up and expenses
• Violation of surgical planes
• Encouraging early results

ELIOT TRIAL(intraoperative electron) 2013

T<2.5CM,Age >48 years

BCT+ Whole Breast RT vs BCT+ ELIOT

5 year event rate for IBRT 4.4% in the IORT group and 0.4% in the EXRT group.
External Beam Radiation
Machine: Linear Accelerator

Technique: External Beam RT

3DCRT,IMRT,Tomotherapy Advantages:
Good coverage of target
Good dose homogeneity

Problems:
 Issues of movement with breathing .
 More margin
 Higher intergral dose-lungs, heart
Advantages:

• Non invasive(complication of surgery like seroma and infection can be

avoided)
• Widespread availability
• Technically less demanding

PLANNING

• CTV- Tumor bed on CT including ,surgical clips plus 1cm margin inside breast tissue
• PTV- CTV+1cm margin
• Prescribed dose-38.5 Gy in 10 fraction bd over 5-8 days(Minimum interfraction
interval 6 hrs)
 • Treated with 3-5 non-coplanar conformal fields

Interstitial 3DCRT/ Introperat Intraopera Mammosite

Brachythera IMRT ive tive Xrays
py electrons TARGIT
(ELIOT)

Covera Variable Best Good Good Good

ge of
target
volume
Thickne 1-2cm 2-2.5cm 1-2.5cm Dose 1cm
ss of prescribed at
target 1mm.
treated At 10mm:5-7Gy

Sparin good least good best good

g of
norma
l breast
Skin dose Least High Least Least (can Variable
shield)

Technical Axilla Almost Axilla, Large Large

limitations Nil brachial cavities, cavitie
plexus, skin irregular s,
cavities irregul
ar
cavitie
s,
close
to
skin,
peripher
y

Drawbacks Adequacy of High Histopathology Very limited Cavity

dose to dept shape
 and
target normal Wider h of irradiation, size
tissues,
coverage motion applicability cavity shape, Skin
dose
Wider size, no
applicability hitopathology

Accelerated Partial-Breast Irradiation Compared With Whole-Breast Irradiation for Early

Breast Cancer: Long-Term Results of the Randomized Phase III APBI-IMRT-Florence Trial

Eligible patients, as previously reported, were women age . 40 years with early BC (maximum
diameter, 2.5 cm) suitable for BCS.13 Extensive intraductal carcinoma, multiple foci cancer, and final
surgical margins , 5 mm represented the main exclusion criteria

The primary end point was to determine the 5-year difference in ipsilateral breast tumor recurrence
(IBTR) between 30 Gy in 5 once-daily fractions (APBI arm) and 50 Gy in 25 fractions with a tumor bed
boost (WBI arm) after breast-conserving surgery.

The 10-year cumulative IBTR incidence in early breast cancer treated with external APBI using IMRT
technique in 5 once-daily fractions is low and not different from that after WBI. Acute and late
treatmentrelated toxicity and cosmesis outcomes were significantly in favor of APBI.

Limitations of apbi

• Highly restrictive selection criteria

• Not many trials showing non inferiorty, none showing superiorty and many NOT
reaching the goal of non inferiorty
• Emergence of new hypofractionated schedules with broader selection criteria.

Sequelae of irradiation in breast cancer:

• Lymphedema and Breast Edema

• Skin and Breast Complications
• Brachial Plexopathy
• Pulmonary Sequelae
• Cardiac Sequelae
• Contralateral Breast Cancer and Irradiation
• Incidence of Other Second Malignancies
• Post irradiation Angiosarcoma of the Breast