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Radiotherapy In Carcinoma Of The Breast

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Radiotherapy In Carcinoma Of The Breast

  1. 1. Radiotherapy in Carcinoma of the Breast Patrick S Swift, MD Director, Radiation Oncology Alta Bates Comprehensive Cancer Center Berkeley, CA
  2. 2. Breast Conserving Therapy BCT <ul><li>70-80% of patients with stage I or II disease are candidates for BCT </li></ul><ul><li>6 major randomized trials comparing mastectomy to BCT </li></ul><ul><ul><li>No difference in DFS </li></ul></ul><ul><ul><li>No difference in OS </li></ul></ul>
  3. 3. Distant Failure 34% 32% 6 859 1983-89 Denmark 82TM 30% 34% 10 903 1980-86 EORTC 10801 39% 34% 20 279 1979-89 US NCI 40% 33% 20 1406 1976-84 NSABP06 54% 51% 20 701 1973-80 Milan I 23% 24% 22 yrs 179 1972-79 WHO BCT Mast. Time pt. # Trial
  4. 4. Overall Survival 67% 67% 6 859 1983-89 Denmark 82TM 82% 79% 10 903 1980-86 EORTC 10801 65% 66% 20 279 1979-89 US NCI 53% 58% 20 1406 1976-84 NSABP06 46% 47% 20 701 1973-80 Milan I 42% 41% 22 yrs 179 1972-79 WHO BCT Mast. Time pt. # Trial
  5. 5. Absolute Contraindications to BCT <ul><li>Repeatedly positive margins </li></ul><ul><li>Multicentric disease ( > 2 quadrants) </li></ul><ul><li>Diffuse malignant calcifications on mammogram </li></ul><ul><li>Prior RT to breast </li></ul><ul><li>Pregnancy </li></ul>
  6. 6. Relative Contraindications to BCT <ul><li>History of scleroderma </li></ul><ul><li>Large tumor in small breast </li></ul><ul><ul><li>Cosmetically undesirable </li></ul></ul>
  7. 7. NOT contraindications to BCT <ul><li>Age </li></ul><ul><li>Skin or nipple retraction </li></ul><ul><li>Histology other than IDC </li></ul><ul><li>Extensive intraductal component </li></ul><ul><ul><li>As long as margins are clear </li></ul></ul><ul><li>Positive nodes </li></ul><ul><li>Location of primary in breast </li></ul><ul><li>Positive family history </li></ul>
  8. 8. Positive Margins after Lumpectomy <ul><li>Single most important predictor of local failure in BCT </li></ul><ul><li>Consider re-excision to get negative margins </li></ul><ul><li>Focal positivity - may be okay </li></ul><ul><ul><li>Especially if chemo or HT given </li></ul></ul><ul><li>Extensive positivity - re-excise! </li></ul>
  9. 9. Extensive Intraductal Component (EIC) <ul><li>Intraductal component a prominent part of the main tumor </li></ul><ul><li>Intraductal carcinoma extends BEYOND the infiltrating margin of the mass </li></ul><ul><li>Of uncertain significance if margins are clearly negative </li></ul>
  10. 10. Treatment by Stage
  11. 11. DCIS Ductal Carcinoma in Situ <ul><li>MRM is acceptable </li></ul><ul><ul><li>no node dissection </li></ul></ul><ul><li>BCT is an acceptable approach if: </li></ul><ul><ul><li>Lesion is small (< 3 cm) </li></ul></ul><ul><ul><li>Margins must be negative </li></ul></ul><ul><ul><ul><li>preferably > 10 mm in all dimensions </li></ul></ul></ul><ul><ul><li>Nuclear grade is low to intermediate </li></ul></ul><ul><ul><li>Adjuvant radiotherapy can be delivered </li></ul></ul><ul><li>S alone can be considered if margins >10 mm </li></ul><ul><ul><li>controversial </li></ul></ul>
  12. 12. NSABP-17 <ul><li>814 pts. with DCIS, negative margins </li></ul><ul><li>Randomized to RT v no RT </li></ul><ul><ul><li>50 Gy to entire breast, no boost </li></ul></ul><ul><li>At 12 years, local failure rates </li></ul><ul><ul><li>31.7% for no RT </li></ul></ul><ul><ul><li>15.7% for RT </li></ul></ul><ul><li>Only comedo necrosis was a significant factor predicting for local failure </li></ul>
  13. 13. EORTC 10853 <ul><li>500 pts with DCIS, clear margins </li></ul><ul><li>Randomized to 50 Gy whole breast or no RT </li></ul><ul><li>At 4.25 years, local failure </li></ul><ul><ul><li>16% no RT </li></ul></ul><ul><ul><li>9% with RT (p=0.005) </li></ul></ul>
  14. 14. UKCCCR DCIS Working Group <ul><li>1030 pts with DCIS, clear margins </li></ul><ul><li>S alone </li></ul><ul><li>S + Tam </li></ul><ul><li>S + RT </li></ul><ul><li>S + RT + Tam </li></ul><ul><li>At 4.4.years, local failure </li></ul><ul><ul><li>14% in no RT </li></ul></ul><ul><ul><li>6% in RT arm </li></ul></ul><ul><ul><li>S + Tam intermediate </li></ul></ul>
  15. 15. Radiation Technique DCIS <ul><li>Opposed tangential fields </li></ul><ul><li>Breast only </li></ul><ul><li>No boost </li></ul><ul><li>1.8-2.0 Gy daily to 50 Gy </li></ul><ul><li>2.65 Gy daily to 40 Gy </li></ul>
  16. 18. Van Nuys Prognostic Index Scores of 3-4 - 98% local control without RT Scores of 5-7 - 32% failed without RT, 16% with RT Scores of 8-9 - 100% failure without RT, 60% with RT
  17. 19. Radiation Technique T1-2 N0 <ul><li>Opposed tangential fields </li></ul><ul><li>Breast only </li></ul><ul><li>Boost optional </li></ul><ul><li>50 Gy in 25-28 fractions </li></ul><ul><li>42.5 Gy in 16 fractions (Canadian) </li></ul>
  18. 20. ASTRO 2008 Plenary 42.5 Gy in 16 fractions v. 50 Gy in 25 fractions
  19. 21. ASTRO 2008 Plenary <ul><li>Canadian Trial 1993-1996 </li></ul><ul><li>N= 1234 women </li></ul><ul><li>Median followup - 12 years </li></ul><ul><li>Local recurrence at 10 years - 6% </li></ul><ul><li>Excellent cosmesis at 10 yrs - 70% </li></ul><ul><li>No difference between 16 and 25 fractions </li></ul>
  20. 23. If getting chemotherapy… <ul><li>Radiation is usually withheld until after the systemic therapy is complete </li></ul><ul><li>Delay of up to 4-6 months from surgery generally not considered a problem </li></ul><ul><li>Possible problem with inflammatory cancer or other locally aggressive cancers </li></ul><ul><li>Hypofractionated schemes may allow for early RT while waiting for Oncotype </li></ul>
  21. 24. Surgery alone without RT? <ul><li>Meta-analysis results </li></ul><ul><li>Lancet . 2005 Dec 17, vol. 366(9503):2087-106 </li></ul><ul><li>“ Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials.” </li></ul><ul><li>An average of 75% reduction in local failure rates with the addition of RT, in even the lowest risk groups. </li></ul><ul><li>A survival benefit was seen in the meta-analysis </li></ul>
  22. 25. Surgery alone without RT? <ul><li>One possible subset may benefit </li></ul><ul><li>Patients > 70 years of age </li></ul><ul><ul><li>with small ER+ tumors </li></ul></ul><ul><ul><li>who will get tamoxifen </li></ul></ul><ul><li>No survival benefit with RT </li></ul>
  23. 26. Radiation Technique T3-4 (after neoadjuvant chemo) <ul><li>Opposed tangential fields </li></ul><ul><li>Boost </li></ul><ul><ul><li>10 Gy for neg margins </li></ul></ul><ul><ul><li>18 Gy for positive or close margins </li></ul></ul><ul><li>50 Gy in 25-28 fractions </li></ul>
  24. 27. Nodal Irradiation <ul><li>N0 - no role for axillary RT </li></ul><ul><li>N+ </li></ul><ul><ul><li>1-3 nodes, “adequate sampling” - no RT </li></ul></ul><ul><ul><li>> 4 nodes, RT to SCLV and axilla </li></ul></ul><ul><li>IM Nodal RT </li></ul><ul><ul><li>> 4 axillary nodes positive </li></ul></ul><ul><ul><li>Medial T3 tumors with any nodes positive axilla </li></ul></ul><ul><ul><ul><li>Awaiting results of two large trials (France and EORTC) </li></ul></ul></ul>
  25. 28. Full SCLV Field
  26. 29. IM Nodal Radiation Technique
  27. 31. Post-mastectomy RT <ul><li>Indications </li></ul><ul><ul><li>T3 lesions with any positive nodes </li></ul></ul><ul><ul><li>Smaller lesions with > 3 nodes </li></ul></ul><ul><ul><li>T4 lesions </li></ul></ul><ul><ul><li>Pectoralis fascia involvement </li></ul></ul><ul><li>Technique </li></ul><ul><ul><li>Tangential beams for the chest wall </li></ul></ul><ul><ul><li>Axillary/SCLV coverage </li></ul></ul><ul><ul><li>IM node coverage for medial lesions or > 3 nodes positive </li></ul></ul>
  28. 32. Post-MRM RT Trials (all with chemo and modern RT) 36% 35% No RT 45% 8% RT 1375 Danish 82c 46% 33% No RT 54% 13% RT 318 Vancouver 45% 32% No RT 54% 9% RT 1708 Danish 82b Overall Survival Local failure
  29. 33. RT Complications <ul><li>Lymphedema </li></ul><ul><ul><li>After full axillary dissection + RT - 37% </li></ul></ul><ul><ul><li>Level I/II dissection + RT - 7% </li></ul></ul><ul><li>Rib fracture - 1.8% </li></ul><ul><li>Pneumonitis - 1-5% </li></ul><ul><li>Cardiac toxicity - avoidable </li></ul><ul><li>Radiation-induced sarcoma </li></ul><ul><ul><li>0.78% at 30 yrs. </li></ul></ul>
  30. 34. Reducing Risk <ul><li>Respiratory Gating </li></ul><ul><li>IM nodal techniques </li></ul><ul><li>IMRT </li></ul>
  31. 39. Partial Breast Irradiation <ul><li>RTOG / NSABP Trial comparing </li></ul><ul><ul><li>Standard whole breast RT </li></ul></ul><ul><ul><li>3D conformal technique </li></ul></ul><ul><ul><li>Mammosite </li></ul></ul><ul><ul><li>Interstitial Implant technique </li></ul></ul><ul><li>5 days, twice daily radiation </li></ul><ul><li>Outcome results pending </li></ul>

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