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Breast Cancer Treatment

for
Non-Invasive Cancers and
Early Invasive Cancer
Dr Suranjan Maitra
PGT, Radiotherapy
NRSMCH
1

NonInvasive
Cancers

Early
Stage
Invasi

Non-Invasive Diseases
LCIS
DCIS
Pagets Disease

Lobular Ca in situ
<15% of non-invasive ca
Multicentric in 90% of specimens
Bilateral in 35-59% cases
10% Invasive ca has associated LCIS
ER positive
Must at diagnosis:
Bilateral Mammogram
Core Biopsy/FNAC
Pathology Review
Importance of Mammogram:
LCIS: A marker for increased risk for
subsequent development of invasive
(usually ductal carcinoma), equally
both for IBTR and CBTR

Lobular Ca in situ
Surgical Excision and Biopsy
is must to proceed for
management.
Management is done
according to associated DCIS
or Invasive Ca disregarding
the presence of LCIS.
If margins are positive for
LCIS, additional surgery to
obtain clear margins for LCIS
is not required.
7

LCIS as Sole Histology


Most widely accepted approach: Close
observation with mammographic
surveillance
Pleomorphic LCIS clear margin??
Patients with highest risk (Young; diffuse
high grade lesion; Family history):
Bilateral Prophylactic Mastectomy
Tamoxifen alone reduces the risk by 56%.
8

Pagets Disease
Rare entity: <5% of all Breast
Ca cases; In fifth-sixth decade.
D/d: Eczema (B/L in Eczema)
Palpable mass present in 50%
cases (Invasive Ca in 90%).
If no palpable mass, 66-86%
underlying DCIS.
Prognosis and management
according to underlying
disease.
9

Pagets Disease - Treatment


Complete excision of Nipple Areola
Complex with microscopically clear
margins for both Pagets and
associated malignancy.Followed by:
Whole Breast RT
5 Year Local Recurrence Rate of 5.2%
(EORTC Study)
10

Ductal Ca in situ

Pure DCIS: No indication of Axillary


dissection.
Axillary node involvement is rare
(0% to 5%)
Apparent pure DCIS: Upto 25%
cases turn out to be Invasive Ca in
lumpectomy specimen.
Thus, if Mastectomy is performed:
SLNB preferred.

If lumpectomy includes Axillary tail,


SLNB preferred (as surgery
compromises future SLNB in the rare
event of associated Invasive Ca)
11

DCIS - Recurrences
Recurrence is 50% DCIS and 50% Invasive Ca.
Risk Factors for Recurrence:
1)Age <50yrs
2)Palpable mass
3)Close (<1mm) or involved margins
4)High Grade
5)Diameter >1cm
6)Presence of Comedo Necrosis.
12

Van Nuys Prognostic


Index
Van Nuys Prognostic Classification:
Group 1 Non-high nuclear grade without necrosis
Group 2 Non-high nuclear grade with necrosis
Group 3 High nuclear grade with or without necrosis

Silverstein MJ, The American Journal of Surgery.


2003 Oct;186(4):337-43

13

DCIS Local RT: NSABPB17 trial

14

DCIS - Treatment
Whole Breast RT following lumpectomy
reduces the recurrence rate by 50% in DCIS.
Boost to tumor bed by 10 Gy is recommended
in cases with close margins and age <50yrs.
MRI may be advised in patients suspected to
have multi centric disease.
Patients without any high risk feature: Surgical
Excision alone is sufficient.
15

16

DCIS Role of TAM: NSABP B-24 trial


Conclusion
Patients in NSABP B-24 with ERpositive DCIS receiving adjuvant
tamoxifen after standard therapy
showed significant reductions in
subsequent
All are P/lumpectomy
+ P/WBRT
breast
cancer. The use of
Median F/u: 14.5yrs
adjuvant
tamoxifen
should
be
Reduces the recurrence rate by 3.4% (HR 0.30,
considered
for patients
with DCIS.
p<0.001) in ipsilateral
IBTR.
Absolute reduction in Contra lateral Breast Ca by 3.2%
(HR 0.68, p=0.02)
D. Craig Allred et al, JCO, 2012

17

DCIS Simple Mastectomy


Indications of Simple Mastectomy in
DCIS:
Multicentric Disease
Diffuse Microcalcifications
Family History

18

19

Treatment of Invasive Carcinoma

Definitive therapy of
Ca Breast

Evolution of
Breast Surgery

20

W S Halsted (1896) : Radical


Mastectomy (removal of all breast
tissue, overlying skin, and both
pectoralis muscles , complete en bloc
removal of the axillary lymph nodes.
Samson
Handley(1920)
:
Extended
Radical
Mastectomy
(Included removal of IMC LN)
D. H. Patey & W.H.Dyson (1948) :
Modified
Radical
Mastectomy
(Pectoralis Major preserved )
Kennedy & Miller(1963) : Total or
Simple mastectomy (Pectoral fascia
en block with breast removed , but
both pectoralis preserved , No Ax.
Dissection)
Madden & Auchinclauss (1972) :
Modification of Pateys operation
(Both Pectoralis were preserved )
Breast conserving surgery:
Wide local excision/Lumpectomy
Quadrantectomy

21

The Paradigm shift in Sugery


G.Keynes(1924)- Introduced Milan Trial ( RM Vs QUART ) 1973
technique of conservative
Sx+ radium needle
implantation
Quadrantectomy ( tumor +
23 cm
margin +overlying
skin + underlying fascia.
Lumpectomy : tumour mass
+
narrow margin
Old principle small tumor, large operation was challenged
with new concept small tumor, small operation and
extensive tumor, extended operation.
Conservative surgery and Less mutilating operations.
In-situ disease and Minimal Breast cancer
Veronesi U et al. Cancer 39:28222826, 1977

22

Locoregional treatment of EBC

(Lumpectomy
+ Surgical Ax Staging)
reconstruction

Total Mastectomy
+ Surgical Ax Staging
reconstruction

Preoperative
chemotherapy
If,T2 or T3 tumor
fulfills criteria for BCT
23

NCCN Guidelines Version 3.2015

Lumpectomy
Optimal extent of resection for treatment of EBC not clearly
defined.
Wide local excision with microscopically negative margins is
preferable
to segmental
or Quadrantectomy
Re-excision
at mastectomy
the primary tumor
site recommended when:
Surgical procedure was less than a complete lumpectomy.
Pathologic margins are positive.
Residual suspicious microcalcifications on a postlumpectomy
mammogram.
Extensive Intraductal Carcinoma (EIC).
Tumor size alone is not usually considered an indication for reexcision
For larger T2-T3 tumor NACT f/b breast conservation is
encouraged.

24

BCS+RT
Mastectomy is no longer a standard
of care in breast cancer surgery
BCS is possible in all EBC and is also
practised in LABC
Whole breast RT is compulsory in BCT
Results of BCS+RT and mastectomy
are equivalent
Local control rates are also
significantly improved by use of
boost to tumor bed
25

BCS and Radiation with Mastectomy


for EBC
Institute

IGR

Milan

NSABP
B-06

NCI

EORTC

Danish

Stage

1,2

1,2

1,2

1,2,3

Surgery

2cm
gross
margin

Quadrantectom
y

Lumpectomy

Gross
excision

1 cm gross
margin

Wide
excision

Follow-up(y)

15

20

20

18

10

73

42

46

59

65

79

BCS
BCS followed
followed by
by RT
RT is
is

equivalent
equivalent to
to mastectomy
mastectomy for
for

OS:BCS+RT(%)
M(%)

appropriately
appropriately
selected
selected
patients
65
41
47
58 patients
66

LR: BCS+RT(%)

M(%)

14

14
22
with
with
EBC.
EBC.

10

82

20

12

26

BCS+RT vs BCS

The pooled meta-analysis of


15 RCTs shows a threefold
reduction in local failure & a
small but significant
improvement in OS with RT
after BCS

Vinh-Hung et al. JNCI ( 2004);96:115-121

27

EBCTCG Meta-analysis (lancet


2005)

78 RCTs of EBC.
N= 42 000
7300 had BCS
Local recurrence
rate at 5 years,
after BCS was
reduced by
post-op RT from
26% to 7%.

15-yr breast cancer


mortality was
significantly reduced,
from 35.9% to 30.5%
Overall mortality
reduction with RT was
5.3% at 15-yrs.
Similar proportional
benefit of RT in ALL
stages. Absolute
benefit varies with the
actual risk, according
to stage.
28

Breast Conservation Therapy:


Node negative disease

5 yr gain
16.1%

LR

15 yr gain
5.1%

OS
EBCTCG Lancet 2005,vol 366, 2093

29

Breast Conservation Therapy:


Node positive disease
LR

5 yr gain
30.1%

OS

15 yr gain
7.1%

EBCTCG Lancet 2005,vol 366, 2093

30

Lumpectomy+ Surgical Ax Staging..

4 Ax Nodes (+)

1-3 Ax Nodes (+)

RT to whole breast ( Tumor


bed Boost), Infraclav. &
Supraclav. area , Int. mammary
nodes.

Negative Ax nodes

RT to whole Breast
Tumor bed boost OR
Partial Breast
Irradiation
(PBI)

* In all cases RT should be preceded by Chemotherapy if indicated

NCCN Guidelines Version 3.2015


31

otal mastectomy + Sx. Ax. Staging.

4 Ax nodes (+) : Post Chemotherapy, RT to Chest wall + Supraclav.;


Infraclav. area & Int. mammary nodes.

1-3 Ax nodes (+) : Post Chemotherapy, RT to chest wall + Supraclav. ;


Infraclav. Area & Int. mammary nodes.

Negative Ax nodes + RT to Chest wall + Supraclav. ; Infraclav. area


T3 OR Margin (+)
: & Int. mammary nodes.

Negative Ax nodes +
Tumor 5cm OR
: RT to chest wall
Close margin(< 1cm)

Negative Ax nodes +
Tumor 5cm OR
: No Radiation therapy
Margin > 1cm.

NCCN Guidelines Version 3.2015


32

ow to manage axillary nodes ???


axillary metastasis is the most important prognostic finding
in patients
with potentially curable carcinoma of the breast,
- Giuliano A E

Upto 1990s ALND was gold standard for Axillary Staging


Axillary Dissection:
Low axillary dissection(Level I & II)
Complete Axillary Clearance(Upto Level III)
Staging procedure rather than a therapeutic intervention.
( Fisher B et al,
Surg Gynaecol Obstet 1981)
Unacceptable Complication , Low Yield

Axillary Sampling :
Min. 4 nodes removed at Level I if metastatic AD or Axillary RT
Recognized as staging procedure
Significant morbidity and LR > 10%
33

Adequate ALND???

34

Changing concepts in Axillary staging.

Sentinel lymphadenectomy with focused histopathologic


examination
may eventually eliminate the need for standard ALND to
determine
that a breast
cancerof
patient
is free
axillary
Giuliano
et al, Annals
Surgery.
Vol. of
222,
No. 3, 394-401
metastases.

Sentinel Lymph
Node Biopsy in
Breast Cancer
Ten-Year
Results of a
Randomized
Controlled Study
Veronesi U et al , Ann Surg 2010;251: 595600
35

Seek the Sentinels


99mTc albumin colloid (2ml) injected at
four sites Peritumoral on the day before
surgery (dose = 40 MBq) or on the day of
surgery
(dose = 20 MBq)

Static Scintigraphic images taken after


3hrs (Dual Gamma camera)

Location of Sentinels nodes are marked on skin

Diluted Patent Blue/Isosulphan Blue Dye injected


Peritumorally 3-5 mins prior to incision

Identification based on blue dye mapping &


gamma camera detection

>10 times the background count (as


measured at the antecubital fossa)
defined as sentinel lymph nodes

36

Sentinel nodes dissectionis it sufficient enough??

NSABP-32 Trial
Sentinel-lymph-node resection compared with conventional axillary-lymph-node
dissection in clinically node-negative patients with breast cancer: overall survival
findings from the NSABP B-32 randomised phase 3 trial
Findings
5611 women were randomly assigned to the treatment groups, 3989 had pathologically
negative SLN. 309 deaths were reported in the 3986 SLN-negative patients with follow-up
information: 140 of 1975 patients in group 1 and 169 of 2011 in group 2. Log-rank
comparison of overall survival in groups 1 and 2 yielded an unadjusted hazard ratio (HR) of
120 (95% CI 096150; p=012). 8-year Kaplan-Meier estimates for overall survival were
918% (95% CI 904933) in group 1 and 903% (888918) in group 2. Treatment
comparisons for disease-free survival yielded an unadjusted HR of 105 (95% CI 090122;
p=054). 8-year Kaplan-Meier estimates for disease-free survival were 824% (805844) in
group 1 and 815% (796834) in group 2. There were eight regional-node recurrences as
first events in group 1 and 14 in group 2 (p=022). Patients are continuing follow-up for
longer-term assessment of survival and regional control. The most common adverse events
were allergic reactions, mostly related to the administration of the blue dye.

Interpretation
Overall survival, disease-free survival, and regional control were statistically equivalent
between groups. When the SLN is negative, SLN surgery alone with no further ALND is an
appropriate, safe, and effective therapy for breast cancer patients with clinically negative
lymph nodes.
Krag et al, Lancet 2010 Vol.11.p 927-933

Sentinel nodes positiveWhat is next????

ACOSOG Z0011 Trial


Locoregional Recurrence After Sentinel Lymph Node Dissection
With or Without Axillary Dissection in Patients With Sentinel
Lymph Node Metastases: The American College of Surgeons
Oncology Group Z0011 Randomized Trial
Results: There were 446 patients randomized to SLND alone and 445 to
SLND + ALND. Patients in the 2 groups were similar with respect to age,
Bloom-Richardson score, estrogens receptor status, use of adjuvant
systemic therapy, tumor type, T stage, and tumor size. Patients
randomized to SLND + ALND had a median of 17 axillary nodes removed
compared with a median of only 2 SN removed with SLND alone (P <
0.001). ALND also removed more positive lymph nodes (P < 0.001). At a
median follow-up time of 6.3 years, there were no statistically significant
differences in local recurrence (P = 0.11) or regional recurrence (P =
0.45) between the 2 groups.
Conclusions: Despite the potential for residual axillary disease after
SLND, SLND without ALND can offer excellent regional control and may
be reasonable management for selected patients with early-stage breast
cancer treated with breast-conserving therapy and adjuvant systemic
Giuliano A E et al. Annals of Surgery: 2010
therapy.

- Vol 252

Avoiding axillary dissection in breast cancer


surgery :a randomized trial to assess the role of
axillary radiotherapy

Veronesi U et al. Annals of Oncology 16: 383388, 2005


39

Axillary nodal RT?


Axillary nodal RT is no longer indicated if
complete axillary dissection (>10 LN
sampled) has been performed.
Axillary nodal RT significantly adds to
the lymphoedema morbidity
The only possible indications today are:
incomplete/ no axillary dissection
positive axillary nodes WITH extracapsular
extension (ECE)/ perinodal extension (PNE)
SN+ with no dissection

Justification of Regional Nodal Irradiation:


Interim result of NCIC-CTG MA.20 Trial
Objective: To compare relative effectiveness of RNI to the internal
mammary (IM),Supraclavicular(SC) and high Axillary (Ax) lymph nodes in
addition to WBI after BCS for women with node +ve and high risk node
ve Breast cancer treated with adjuvant systemic therapy

Authors conclusion : The implication of this study is that all


women with node positive disease should be treated with RNI
in addition to WBI.
41
Whelan J T et al. J Clin Oncol 29: 2011 (suppl; abstr LBA10

Is a posterior axillary boost field necessary?


Variability of the depth of supraclavicular and axillary lymph
nodes in patients with breast cancer: is a posterior axillary
boost field necessary?
PURPOSE:
To determine the variability of the depth of supraclavicular (SC) and axillary (AX) lymph nodes in patients
undergoing radiation therapy for breast cancer and to relate this variability with the patient's
anterior/posterior (A/P) diameter. The dosimetric consequences of the variability in depth are explored and
related
to the need for a posterior axillary boost field.
RESULTS:
The maximum depth of the SC lymph nodes ranged from 2.4 to 9.5 cm (median, 4.3 cm). The depth was
less than 3 cm in 4 patients, 3-6 cm in 39 (80%), and greater than 6 cm in 6 patients. There was a linear
relationship between the SC lymph node depth and the A/P diameter. The depth of the SC lymph nodes in
cm equals approximately one-half of the A/P diameter minus 3.5 (r(2) = 0.69). In 94% (46 of 49) of patients,
the SC lymph node depth was between one-fifth and one-half of the A/P diameter. The depth of the axillary
lymph nodes ranged from 1.4 to 8 cm (median, 4.3 cm). The depth was less than 3 cm in 8 patients, 3-6 cm
in 32 (65%), and greater than 6 cm in 9 patients. The AX lymph node depth in cm equals approximately
one-half of the A/P diameter minus 3 (r(2) = 0.81). In all patients, the AX lymph nodes were shallower than
mid-depth. The depth of the SC and AX lymph nodes was within +/- 1 cm in 53% (26 of 49) of patients. The
AX lymph nodes were located at >/= 1 cm shallower or greater depth than the SC in 24.5% (12 of 49) and
22.5% (11 of 49) of patients, respectively. If an anterior 6-MV beam only is used to treat the SC and AX
lymph nodes in these 49 patients, the dose to the AX is within +/- 5% of the SC dose in 53% (26 of 49)
patients and is 90% or more of the dose delivered in the SC in 90% (44 of 49) of patients.

CONCLUSION:
The maximum depth of the SC and AX lymph nodes varies widely and is related to
the patient's size represented by the A/P diameter. In most patients, the AX
lymph nodes lie at approximately the same depth or shallower than the SC.
Therefore, the rationale for a posterior axillary boost field needs to be further
assessed. When the AX and SC lymph nodes are deep, opposed supraclavicular
and axillary fields and/or the use of a higher energy beam might be reasonable.

Bentel GC et al. Int J Radiat Oncol Biol Phys 2000 Jun


1;47(3):755-8.

Before
Offerin
g BCT

43

ACRACSCAPSSO Practice Guideline


For BCT : 4 Critical elements
History and physical examination.

Breast imaging.

Histological assessment of the resected breast


specimen.

Assessment of the patient's needs and expectations.


44

HPE Report Importance

Details of specimen

Laterality and quadrant of excised tissue


Type of surgical procedure
Measured size of tumor
Histological type and grade
Resection margin distance
Margin status
Coexistent DCIS or EIC
Peritumoral Lymphovascular invasion
Presence and location of micro calcification
Lymph node status (No.; Size ; ECE, level )
ER & PR and HER2/neu status
45

46

Treatme
nt
volume
Whole
Breast

Supraclav

Axilla

Internal
Mammary

Indication

Routinely following BCS

cN2-N3 ds
>4+LN after AD
1-3+LN with High RF
Node +SLN with no AD
High risk with no dissection
N+ with extensive ECE
SN+ with no dissection
Inadequate axillary
dissection
High risk with dissection

# size/
Total
technique dose
2Gy or 1.8
Gy/tangents
Wedges
/dynamic
wedges to
optimize
homogeneity
1.8-2Gy
AP or AP-PA

4550.4Gy

Comment

Consider omission
of RT
In elderly with stage
I (ER +) and co
morbidities

45-50.4Gy May omit with 1-3


positive nodes in
selected cases

1.8-2 Gy
45-50.4 Gy Axilla may be
AP-consider
intentionally included
posterior axillary
With use of high
boost if
tangents
suboptimal
coverage only
Individualized but consider for 1.8-2Gy
45-50.4 Gy
+Ax. Nodes with Central &
Partially Wide
Medial quadrant lesions
tangents or
Stage III breast cancer
separate IM
+SLN in IMN chain
electron/photon
+SLN in axilla with drainage
47
to IM on Lymphoscintigraphy

Hypofractionated RT
Started as an empirical practice in
government-run health care systems of UK
and Canada
Initially, a purely logistical exercise to reduce
treatment duration & create machine space
Recently, 2 large trials, START-A and START-B,
have validated that clinically as well,
hypofractionated RT is safe and effective.
In fact, even while delivering a lower BED, the
hypofractionated regimens have shown a
survival advantage over conventional
fractionation!

START-A: (19982002)
N=2236
EBC (pT1-T3a, pN0N1, M0)
BCS=1900 (85%) &
MRM=336 (15%)
3 arms:
50 Gy/25#/5 weeks
41.6 Gy/13#/5 weeks
39 Gy/13#/5 weeks
Median FU=5.1 years

Locoregional relapse
rates were 3.6%, 3.5%
and 5.2%, respectively
Late effects, based on
photographs and patient
assessments, were
significantly lower with
39 Gy as compared to
50 Gy
This trial estimated /
of breast cancer as
4.6Gy for tumor control
and 3.4Gy for late
change in photographic
appearance.

Lancet Online. March 19,2008

START-B: (19992001)
N=2215
EBC (pT1-T3a, pN0N1, M0)
BCS=2038 (92%) &
MRM=177 (8%)
2 arms:
50 Gy/25#/5 weeks
40 Gy/15#/3 weeks
Median FU=6 years

Locoregional relapse
rates were 3.3% and
2.2%, respectively
Absolute differences
in locoregional
relapse was -0.7%
(95%CI -1.7% to
0.9%), meaning that
with 40Gy the
relapse rate would
be at most 1% worse
and at best 1.7%
BETTER!

Lancet Online. March 19,2008

Cosmesis

Acharya Tulsi Regional Cancer Center,


Bikaner
51

DFS in Start A & B

Acharya Tulsi Regional Cancer Center,


Bikaner
52

Hypofractionation from the


Radiobiologic viewpoint
UK-FAST: (2004-2007)
N=915
Favourable EBCs after BCS
(age>50 yrs, pT<3cm,
pN0)
3 arms:
50Gy/25$/5 weeks
28.5Gy/5#/5 weeks (onceweekly)
30Gy/5#/5 weeks (onceweekly)
Median FU=37.3 months

Primary end-point was 2 yr


change in photographic
appearance of breast
3-yr physician assessed
moderate to marked breast
adverse effects were 9.5%,
11.1% and 17.3%
respectively.
Conclusion:At 3 yrs median
FU, 28.5Gy/5# (@5.7Gy/#)
is comparable to 50Gy/25#
for breast adverse effects
and significantly milder
than 30Gy/5# (@6Gy/#)
Radiotherapy & Oncology. Epub.2011

Is SCF RT required
at all?
Studies suggest that isolated SCF recurrences
are uncommon, for both pN1 and pN3 disease
The main risk for pN3 disease, is not SCF
recurrence but distant metastasis

54

How to execute Radiation therapy..

tment position:

ine, arm abducted 900-1200 and externally rotated

ast tilt board with armrests & other immobilization devices

ral position- For large pendulous breasts (Institut curie)

ne position- For reducing dose to underlying lung , heart & contrlat. breast
( Merchant and McCormick)

Treatment volume :
Targets
Whole breast , Chest wall + small lung tissue
Supraclavicular fossa
Axillary nodes
Breast
Internal mammary nodes ( if indicated)

OARs
Lung
Heart
Opposite
Skin55

56

Simulation and field margins :


Radiation Field
field 2
(Supraclavicular
field) :
Radiation
1(Tangential
fields):

dio-opaque clips placed at margins of tumor bed and/or scars are wired
Lower margins : Upper margin of tangential fields
per margins
Edge of: At
thethe
Head
of of
the
clavicle
Upper: margin
level
cricothyroid
groove
Medial
: 1cm
the midline
along the medial border of
wer margin
: 2margin
cm below
theacross
inframammary
fold
ipsilat. SCM
eral margin
: 2border
cm beyond
all palpable
breast
including
entire Medial
Lateral
: At Coracoid
process(
In tissue
case of( axillary
extension
2/3 rd of scar in post-mastectomy pts.)
Humeral head is included)
dial margin : With Int.mammmary field- at lat margin of int.mammary field
This field
is angled
approximately
5 to 10
from the
the midline
vertical
Without
Int.
mammary fieldAtdegrees
or 1cm over
toward the medial side to avoid treating the cervical spinal cord.

57

Internal Mammary Field borders


Medial border: Midline
Lateral border : Usually 5-6 cm lateral to the midline
Superior border: Abuts the inferior border of
Supraclavicular field
Inferior border: At the xiphoid or higher

58

Posterior Axillary Boost Field borders

edial border: 1.5-2 cm lung to show in portal film


ateral border : Just blocks fall of across the post. Axillary fold
uperior border: Splits the clavicle
uperolateral border: Splits the humeral head
ferior border: At the same level of inferior border of Supraclav field

59

Alignment of Tangential Beam


with Chest Wall Contour

make the post. edge of the tang. beam follow to the downward sloping
our of the ant. chest wall

The collimator angle may be rotated


Patient placed on a slant to make the slope parallel to table
Rotating beam splitter mounted on a tray may be used

eep ( Intrathoracic ) field border must be nondivergent & edges made


anar
Use half beam block technique
Rotate gantry to make symmetric & align post. edge of each tangent

ocenter is typically placed in the center of the field


60

Lung and Heart to be spared optimally.


Central lung distance (CLD) : Lung
distance in the projection of the tangential fields
at the level of the central axis
Maximum lung distance (MLD) : Maximum
perpendicular distance from the posterior
tangential field edge to the posterior part of the
anterior chest wall
Lung length(LL) : Vertical lung distance
included in the radiation port.
Maximal heart distance (MHD) : The width
of heart in the tangent fields at its maximal
level.
Maximal heart length (MHL) : The maximal
lengthKong
in tangential
fields
the heart
FM et al.
Int referring
J Radiat to
Oncol
Biol
contour
Phys
2002;54:963-971

61

Lung and Heart to be spared optimally.


Usually up to 2 to 3 cm of underlying lung is included in the
tangential portals.
The best predictor of the percentage of Ipsilateral lung volume treated
by the tangential fields was the CLD

CLD

Ipsilat. Lung

included
(Predicted)
1.5 cm
2.5 cm
3.5

6%
16%
26%

If CLD > 3cm in Lt. Breast irradiation, to avoid significant heart


irradiation a Medial Tangential Breast Port is used. (3-5 cm wide
similar to Int. mammary port and beam is angled 10to 15 laterally)
62

The Radiation Beam


4-6 MV photons are preferred
> 6 MV photons causes underdosing of superficial tissues
beneath the skin.
Higher energy photons preferred for large breasts to reduce the
Integral Breast Dose.
Wedges and compensators may be used to reduce dose
inhomogeniety.
If field separation >22cm higher energy photons( 10-18 MV)
required for all or
part of the treatment to reduce dose inhomogeniety

63

Geometric matching of Tangential and SCV


Fields

ns at edge of sharp Linac beams produces Hot spots just beneath skin at
d junction (d/t divergence of Tangential fields and Supraclavicular field int
other.) SEVERE MATCHLINE FIBROSIS or RIB FRACTURE

hods of matching:

r SCV field :- Hanging Block Technique

r tangential field :Inferior Angulation


Hanging Block Technique
Rotating Beam Splitter
Couch Kick technique

gle Isocenter Technique


64

65

ometric matching of Tangential fields


d IMC fields

66

TUMOUR BED
BOOST

67

65% to 80% of breast recurrences after conservation


surgery and irradiation occur around the primary tumor
site
Strong rationale for a tumor bed
boost

68

Boost modalities

Target Volume for Boost

For Electrons : 20 30mm.

Delineation of Target area


En-face
electrons
For BT
HDR brachytherapy

+/ unknown margin Clinical


in EBC: 30mm.
3DCRT/ IMRT/ VMAT
Mammography

ve
margin
:
15
mm
is adequate.
IMPT
Surgical clips usu 5
For LABC
: Not defined. An area of
Modulated
electrons
Ultrasonography
(MERT)
present
trials.

scan
Liberal margin (evenCT
extra 5 mm) will
MRI
double the
Per-op placement of catheters
CTV.
(Ref: ESTRO Recommendations, 2002)

69

Seroma contouring guidelines


STV ( Seroma Target
Volume)= tumor cavity
CTV= STV+1cm (Edited
from skin and chest wall by
5mm)
PTV=CTV+1cm
STV to Exclude breast
tissue stranding, but
Include surgical clips (if
present)

Wong et al. IJROBP, Vol.66, No.2,pp. 372-376,200


70

APBI
Twin rationale:
(1) Most breast cancer recurrences
occur in the index quadrant.
(2) Many patients cannot come for
prolonged 5-6 week adjuvant
radiotherapy for logistic reasons.

71

APBI: Indications
(ASTRO recommendations)
Suitable outside clinical
trial
(ALL of)
Age>60 years
BRCA negative
T1N0M0 (pT<2cm)
EIC negative
Unifocal
IDC/ favourable histology
Margin negative (>2mm)
LCIS negative
ER positive

Suitable only in a
clinical trial
(ANY of)
Age 50-59 years
BRCA negative
T1/2,N0,M0 (pT2-3 cm)
EIC <3cm
Unifocal
ILC
Margin close (<2mm)
ER negative
72

ASTRO: unsuitable for


APBI
ANY OF:

T>3cm/T4 or N+
BRCA mutated
High grade
LVSI extensive
EIC+ve (>3cm)
Multifocal disease (contraindication to BCS
per se)
Margin positive
Received neoadjuvant chemotherapy
73

APBI: Interstitial Brachytherapy

2
16
0
10
234 1112
5 7

74

Multi-catheter interstitial brachytherapy


First developed APBI technique
Longest experience with extensive followup but
technically demanding
Image guided placement of After loading
catheters
at 1.5-2 cm interval

Dosage : 34 Gy/ 10 # / twice a day / 5d


OR
32 Gy/ 8 # / twice a day/ 4 d
More incidence of subcutaneous fibrosis
and fat necrosis

2.7
Gy
3.4
Gy
5.1
Gy
75

Mammosite Radiation Therapy System


First alternative APBI technique Approved by
US FDA in May, 2002

Double lumen catheter (15 cm length,6cm diam.)


within a distally located inflatable balloon (4-5cm or
5-6 cm size) placed inside lumpectomy cavity.
After inflation, balloon symmetry, an
overlying skin distance of 5 mm, and
lumpectomy cavity conformance with the
balloon surface are evaluated
3.4 Gy
1cm

4.25
Gy
5.1 Gy

76

3DCRT and IMRT

77

TARGIT
TARGIT-A trial results

Compared TARGIT with Conventional


Whole breast EBRT
LR at 4 years was 12.0% (95% CI 053
271) in TARGIT & 095% (039231) in
EBRT (diff. between groups 025%, 104
to 154; p=041).
Overall complication was similar ( 3.3%
Vs 3.9% )
RTOG Gr.3 Radiation related toxicity
was less in TARGIT
( 0.5% Vs 2.1% ,p= 0.002 )
Concluded as Single dose TARGIT
should be considered as an alternative to
78
EBRT delivered over several wks.

Highlights of 3D Conformal External Beam APBI

tractive because
1) Non invasive , 2) Homogeneous dose pattern , 3) Less toxicity

x. dose constrains to surrounding normal structure needs to be defined


Impact of breathing motion and set-up error on
treatment accuracy
are to be investigated.

79

ELIOT
80

Intra Operative Electron Radio Therapy

tron ( 4-12 MeV) / Novac7 (3-9 MeV)


/ Liac (4-10 MeV)
dose : 21 Gy / 1 #

er cosmesis, Easily accessed


elay in RT- LR ,
er radioprotection for normal
ounding structures

Veronesi U et al.(2008)
ecancermedicalscience 2:65

81

IMRT Breast: Why?


Dosimetric advantages include:

(1) better dose homogeneity for whole


breast RT
(2) better coverage of tumor cavity
(3) feasibility of SIB
Forward planned IMRT (field-in-field) is
preferred as it is simple and effective.
82

83

IMPORT trials
(phase III RCTs from UK)
IMPORT High: (2008-ongoing)IMPORT Low: (2006-2010)
To test dose-escalated IMRT To test PBI by IMRT in lowrisk EBC after BCS
in high-risk EBC after BCS
(ALL) IDC/no ILC/pN0/no
High risk by v/o (ANY)
LVE/pT<3cm/unifocal/grade
N+/grade III/T>2/NACT
I,II or III/margin>2mm
received/margin<5mm/age
3 arms:
18-49 yrs/LVE+
WBRT (15#/3 weeks)
3 arms:
WBRT followed by sequential WBRT +PBI (each 15#/3
weeks)
boost (56 Gy/23#)
WBRT with SIB (48Gy/15#) PBI (15#/3 weeks)
WBRT with SIB (53Gy/15#)
Primary endpoint: Local
control (ipsilateral)
Primary endpoint: Breast
fibrosis
84

PBI or WBI ???...still to be answered !

Randomized multientric phase-III study


o compare

Schema for the NSABP B-39/RTOG 0413


Trial

Local Tumor control ,


OS, RFS , DDFS,
Cosmetic results
Perceived convenience
of care in patients
Fatigue and treatment
related symptoms
Acute and late toxic
effects
85

Low Risk

Intermediate
Risk

High Risk

Node negative AND all of


the followings
pT<2cm AND
Grade 1 AND
Absence of peritumoral vascular
invasion AND
HER2/neu gene neither
overexpressed nor amplified
AND
Age35yrs

NODE negative AND


at least one of the
followings
pT>2cm OR
Grade 2-3 OR
Presence of Peritumoral
vascular invasion OR
HER2/neu gene
overexpression or
amplied OR
Age<35yrs
NODE positive(1-3)
AND
HER2/neu gene
overexpression or
amplified

NODE positive(13) AND


HER2/neu
overexpression or
amplified
NODE positive (4
or more involved
nodes)

Endocrine
Responsive

ET or Nil

ET alone , or
CT+ ET

CT+ET

Endocrine
Response
Uncertain

ET or Nil

CT+ ET

CT+ ET

CT

CT

Endocrine
Non
responsive
Goldhrisch

NA

A et al, Meeting highlights : International expert consensus on


the primary therapy for EBC 2005 .Ann Oncol 2005;16:1569-158386

Follow up of BCT
Post radiation B/L mammogram - within first year.
H+Ph.Ex -3mnthly x 3yrs ;6mnthly x following 2yrs and annually thereafter.
After BCT, a diagnostic mammogram -6-12mnthly x 2yrs and yearly
Thereafter
Monthly self-breast examination (supine and upright position.)
At least yearly evaluation (even 10yrs after Rx)- d/t late breast relapses
and occasional distant metastasis
Unnecessary tests are discouraged
87

lumpectomy

nodal status

50 Gy

Compensators
wedge

supraclavi

electron boost

4-6 MV photons
diffuse

Take cancer
Breast
MLD MHD

WBI
Home
IMRT
boost

margins
heart

CHD

ALM ANAC

+vefollowed by RT is equivalent to mastectomy for


1.BCS
margin
tangential
appropriately
selected
patients with EBCCLD
lung
Toxicities internal mammary
skin
nodes
V2Gy
2.SLNB without
AD may
be sufficient management
selected group
of
half beam block
25-28
fraction
IOR
EBC pts treated with BCS and adjuvant therapy
field matching

conservation therapy
T

APBI
isodose
sentinel node mammosi
i.e.

V30

EIC

conformal
multileaf
adjuvant collimator

3.Outcome of BCT ishot


dependent
on execution
of RT which is
spot
re-excision
SIB
technically
demanding

couch kick technique

TARGIT

systemic therapy

lung V20

pregnancy
local relapse

te

QUART

prone position
Overall survival

ELIOT

Her2-neu

interstiti
recurrenc
al
ER/
e PR

cosmesis

IOET

tamoxifen

breast
board

EORTC
NSABPtumor
B-06 volume gives improved local
4. Radiation Boost to primary
10801
tylectomy
single isocenter
Control but minimal
benefit
axillary survival
3-D
CRT
DCIS
divergence
opp. breast
nodes
dose
CO60
medial
breast
5.PBI/APBI though results are promising
, still not
accepted
as
inhomogeniety
standard of care and needs further evaluation
port technique
PTV
EBCTGG
BRCA 1/2
CTV therapy
6.Systemic
as Neoadjuvant
results in
Stage
I & II or adjuvant therapy
0 - 120
isocenter
mammogram
90as
better outcome
in terms of downMRM
staging as well
LRC0 abduction
7.Close and careful monitoring is essential during follow-up period
to detect
88
both local recurrence as well as distant metastasis

89