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Radiotherapy In Early Breast Cancer


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gist of radiation therapy in early brast cancer; includes BCT, APBI, IORT.

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Radiotherapy In Early Breast Cancer

  1. 1. RADIOTHERAPY IN EARLY BREAST CANCER Dr. T. Sujit A M O ( Radiation Oncology ) Valavadi Narayanaswami Cancer Centre, G.Kuppuswamy Naidu MemorialHospital, Coimbatore - 641037, Tamilnadu, India March 2007
  2. 2. BCT Vs Mastectomy Trials <ul><li>NSABP B- 06 </li></ul><ul><li>EORTC 10853 </li></ul><ul><li>Institut Gustave-Roussy trial </li></ul><ul><li>Danish Breast Cancer Group </li></ul><ul><li>US National Cancer Institute study </li></ul><ul><li> Survival and tumor control rates with BCT similar to Mastectomy </li></ul>
  3. 3. RT IN DCIS <ul><li>As part of BCT </li></ul><ul><li>NSABP 17 and EORTC 10853 trials proved that local recurrence was reduced with the addition of RT to BCS ( 15% vs 31% ) </li></ul><ul><li>Obtaining a negative margin is very important to prevent recurrences. </li></ul><ul><li>Whole breast RT with a boost is the standard radiotherapeutic management </li></ul>
  4. 4. RT IN EARLY INVASIVE BREAST CANCER – B C T <ul><li>Post operative radiation delivered to the breast or part of it with an aim to reduce recurrences. </li></ul><ul><li>Involves irradiating the entire breast by EBRT and giving an additional boost to the tumor bed by means of electrons, photons or brachytherapy. </li></ul><ul><li>Accelerated Partial Breast Irradiation completes the entire course of RT in a period of 5 days using brachytherapy. </li></ul>
  5. 5. WHOLE BREAST RT <ul><li>Treatment position – Supine with arm abducted; alpha cradle / breast board. </li></ul><ul><li>Irradiated volume should include entire breast and chest wall. </li></ul><ul><li>Field borders: </li></ul><ul><ul><li>Upper : Head of clavicle </li></ul></ul><ul><ul><li>Lower : 2 cm below inframammary fold </li></ul></ul><ul><ul><li>Lateral : Mid axillary line </li></ul></ul><ul><ul><li>Medial : at or 1 cm over midline </li></ul></ul>
  6. 6. WHOLE BREAST RT <ul><li>Energy : Usually 6 MV photons. In patients with wide bridge separation ( > 22cm ) higher energies are used. </li></ul><ul><li>Dose : 46 – 50 Gy / 2 Gy per # / over 5 weeks </li></ul><ul><li>Boost dose : 10 – 20 Gy depending on excision margins. </li></ul>
  7. 7. RT BOOST TO TUMOR BED <ul><li>Rationale : Local recurrences tend to be primarily in and around the primary tumor site – boost  risk of marginal recurrence. </li></ul><ul><li>Given by either EBRT or Brachytherapy </li></ul><ul><li>EBRT – photons or electrons </li></ul><ul><li>Brachytherapy – LDR or HDR </li></ul>Lyons Breast Cancer trial , EORTC ( Bartelink et al )
  8. 8. ACCELERATED PARTIAL BREAST IRRADIATION <ul><li>Delivers an accelerated course of radiation treatment to a small volume of breast tissue in and around the primary tumor site. </li></ul>
  9. 9. RATIONALE OF APBI <ul><li>~ Higher dose of RT can be given than by conventional RT </li></ul><ul><li>~ Reduces overall treatment period considerably </li></ul><ul><li>~ Patient convenience may increase acceptance of radiation treatment after breast-conservation surgery </li></ul>
  10. 10. METHODS OF DELIVERING RT <ul><li>1. IOERT </li></ul><ul><li>2. BRACHYTHERAPY </li></ul><ul><li>~LDR </li></ul><ul><li>~HDR </li></ul>
  11. 11. IOERT <ul><li>~ 1st studied by Abe ( University of Kyoto ) using Co 60 </li></ul><ul><li>~ 1 st IOERT using Linac – by Henschke & Goldson in 1976 </li></ul><ul><li>~ Used IOERT mainly as a boost. </li></ul>
  12. 12. IOERT - EQUIPMENTS <ul><li>~ Dedicated OT with Linac to avoid logistical incoveniences. </li></ul><ul><li>~ LINAC - 6 – 12 MeV energy sufficient </li></ul><ul><li>~ COLLIMATION / APPLICATOR SYSTEM: </li></ul><ul><li> lucite or aluminium applicators </li></ul><ul><li> conical / circular / rectangular / elliptical with bevelled or unbevelled edges </li></ul><ul><li>~ “pancake” ionization chamber for dosimetry </li></ul><ul><li>~ patient monitoring facilities </li></ul>
  14. 14. IORT - BREAST DOSE : 10 – 20 Gy IN A SINGLE FRACTION TOTAL PROCEDURE: 30 – 45 min TREATMENT TIME : 2 – 4 min EBRT ( IF REQUIRED ) – AFTER 4-6 WEEKS Single 21 Gy fraction is equivalent to 60 Gy / 30 # ( Veronesi et al )
  15. 15. HDR BT <ul><li>~ Implants </li></ul><ul><li>~ Can reach areas inaccesible by electron applicators </li></ul><ul><li>~ Can be used to treat deep seated tumors </li></ul><ul><li>~ Logistical advantage - portable </li></ul>
  16. 17. HDR BT IN APBI <ul><li>( As sole modality of radiation ) </li></ul><ul><li>~Criteria: ( ABS RECOMMENDATIONS ) </li></ul><ul><li>T1,T2 < 3 cm </li></ul><ul><li>N0 </li></ul><ul><li>Post lumpectomy with ALND </li></ul><ul><li>~Two plane or volume implant </li></ul><ul><li>~Catheters 1 – 1.5 cm apart </li></ul><ul><li>~Min. distance of 1- 2 cm from skin </li></ul><ul><li>~Dose prescription should cover 2 cm of excision margins </li></ul><ul><li>~DOSE : HDR – 32 Gy in 8 # - </li></ul><ul><li>2 # daily 6 hrs apart over 4 days </li></ul><ul><li> LDR – 45 – 50 Gy over 4 days </li></ul><ul><li>~No significant difference in results of HDR Vs LDR </li></ul>
  17. 18. HDR BT AS BOOST <ul><li>~ Following 45 – 50 Gy of EBRT </li></ul><ul><li>~ Dose : 10 – 20 Gy </li></ul><ul><li>~ Can be treated within 6 hrs of surgery </li></ul><ul><li>~ Vicini et al : I 125 permanent implants </li></ul>
  18. 19. MAMMOSITE <ul><li>~Device consists of a catheter with an inflatable balloon at one end. </li></ul><ul><li>~The other end can be connected to a HDR remote afterloading machine. </li></ul><ul><li>~The balloon is inflated with saline to fill the lumpectomy cavity. </li></ul><ul><li>~Catheter is preferably inserted at the time of surgery. </li></ul><ul><li>~CT films are taken for dosimetric planning purposes </li></ul><ul><li>~DOSE: </li></ul><ul><li>As sole modality : 34 Gy / 10 # over 5 days, </li></ul><ul><li> 2 # per day 6 hrs apart </li></ul><ul><li> As boost : 14 – 16 Gy in 4 # over 2 days, </li></ul><ul><li> 2 # per day 6 hrs apart </li></ul>
  20. 21. IOERT Vs HDR IORT 45 – 120 min Total procedure time: 30-45 min TREATMENT RESULTS ARE EQUAL WITH REGARD TO LOCAL CONTROL, SURVIVAL AND COSMESIS. Portable, but requires shielding Logistical problems Custom made applicators for different anatomic locations Standard applicators for all patients Can be use in inaccessible sites Difficult to use in certain anatomic locations Not suitable Large tumor beds can be treated Lower dose at depth Higher dose at depth ( 2 cm ) 5 – 30 min Faster treatment time : 2-4 min > 100 % variation Better dose homogeneity: < 10% variation from surface to depth HDR IORT IOERT
  21. 22. Is APBI a standard treatment? <ul><li>APBI utilising either IOERT or HDR achieves good local control and cosmesis. </li></ul><ul><li>Reduced treatment time translates into better patient compliance for RT. </li></ul><ul><li>However, </li></ul><ul><li> There are no randomised studies comparing APBI with conventional BCT. </li></ul><ul><li> APBI alone, without the use of systemic therapy is less effective than conventional whole breast RT. </li></ul>
  22. 23. RT TO THE AXILLA <ul><li>20 – 40 % of patients with clinically negative nodes have pathologically +ve nodes </li></ul><ul><li>20 % of patients with palpable nodes have histologically –ve nodes. </li></ul><ul><li>Axilla & SCF should be irradiated if > 4 nodes are +ve ( ASCO recommendation ) </li></ul><ul><li>Tumor size > 3 cm is also an indication for axillary RT </li></ul><ul><li>Clinically & pathologically negative nodes – to irradiate or not? </li></ul><ul><ul><li>No benefit for supplementary irradiation after axillary dissection yielding negative nodes or 1-3 positive nodes. </li></ul></ul>
  23. 24. I M N ? <ul><li>IMN are not routinely treated. </li></ul><ul><ul><li>Failure at IMN is rare </li></ul></ul><ul><ul><li>Majority of patients at risk receive adjuvant chemotherapy </li></ul></ul>
  24. 25. 3D CRT & IMRT <ul><li>Overcomes the problem of dose inhomogeneties seen with conventional RT </li></ul><ul><li>Reduces the volume of lung receiving radiation. </li></ul><ul><li>Reduces volume of heart receiving RT </li></ul><ul><ul><li>  Anthracyclines </li></ul></ul>
  25. 26. FACTORS INFLUENCING COSMESIS <ul><li>Surgical factors : Extent of resection, Orientation and length of scar, Closure or not of the tylectomy cavity, separate or continuous axilla-tylectomy scars, extent of axillary dissection. </li></ul><ul><li>Radiation therapy factors: Whole breast RT dose, Dose gradient within the breast tissue, Type and dose of boost, Beam energy, Volume treated, Concurrent use of chemo. </li></ul><ul><li>Host factors : Size and shape of breasts, Compliance with care and hygiene, Intrinsic sensitivity to radiation, concurrent medical illnesses. </li></ul>
  26. 27. SEQUELAE OF THERAPY <ul><li>Arm or breast edema, breast fibrosis, radiation pneumonitis, rib fractures, mastitis, myositis, brachial plexus dysfunction, diastolic cardiac dysfunction. </li></ul>
  27. 28. Thank you