Early Breast Cancer

1. Multi disciplinary Management
Presented by
Dr. Ritam Joarder

2. BCT: How to describe ?????
Optimum RT delivery needs expertise…
To Boost or Not to Boost……
PBI-An emerging concept……
Role of Systemic therapy for EBC……
Essential Anatomy and Initial Evaluation.
Evolution of Surgical Philosophy……

3. This booklet is for women who
have early-stage breast cancer
(DCIS or Stage I, IIA, IIB, or IIIA).
If your cancer is Stage IIIB,
IIIC, or IV this booklet does not
have the information you need.
National Institute of Health
National Cancer Institute
Early Stage Breast Cancer :
What does it mean?....

4. Lymphatics of Breast drains into….

5. Work-up recommended for
Early Stage Breast Cancer….
• History and physical examination
• CBC + platelet count ; LFT
• B/L diagnostic Mammography
• Breast USG (if necessary)
• ER/PR & HER 2 neu status (Not recommended for DCIS)
• Pathology review
• MRI (optional, done if BCT is planned)
• Genetic counselling (if high risk of Hereditary Breast Ca)
NCCN Guidelines Version 1.2012

6.  Additional work-up for Stage I-IIB….
• Bone Scan
• Chest diagnostic CT scan
• Abdominal imaging ( CT/MRI )
• PET scan is not recommended in these stages.
 Additional work up for Stage IIIA
(T3N1M0)..
• All those are included as additional work up for Stage I-IIB
• PET scan is optional.
NCCN Guidelines Version 1.2012

8.  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 Patey’s operation ( Both
Pectoralis were preserved )
Evolution of surgical philosophy……

9. Paradigm shift in Surgical concepts…
• 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 39:2822-2826, 1977
Veronesi U et al. NEJM Vol.305 No.1: p 7-11, 1981
• G.Keynes(1924)- Introduced
technique of conservative Sx+
radium needle implantation
•Quadrantectomy ( tumor + 2–3 cm
margin +overlying skin +
underlying fascia.
• Lumpectomy : tumour mass +
narrow margin
Milan Trial ( RM Vs QUART ) 1973

10. Locoregional treatment of
early stage Breast Ca….
(Lumpectomy
+ Surgical Ax Staging)
± reconstruction
Total Mastectomy
+ Surgical Ax Staging
± reconstruction
Preoperative
chemotherapy
If,T2 or T3 tumor fulfills
criteria for BCT
1
2
3
NCCN Guidelines Version 1.2012

11. I G R Milan
NSABP
B-06 NCI
EORTC
10801 Danish
No. of patients 179 701 1,219 237 874 904
Stage 1 1 1 and 2 1 and 2 1 and 2 1, 2, 3
Surgery 2-cm gross margin Quadrant
ectomy
Lumpec
tomy
Gross excision 1-cm gross
margin
Wide excision
Overall survival (%)
CS+RT 73 42 46 59 65 79
Mastectomy 65 41 47 58 66 82
Local recurrence (%)
CS+RT 9 9 14 22 20 3
Mastectomy 14 2 10 6 12 4
Prospective Randomized Trials Comparing
Conservative Surgery and Radiation with
Mastectomy for Early-Stage Breast Cancer
BCS followed by RT is equivalent to
mastectomy for appropriately
selected patients with EBC.

12. Meta-analysis of
survival and local control in
randomized trials
comparing BCS
with or without radiation.
This meta-analysis
demonstrated a threefold
reduction in local relapse
and a small but significant
increase in survival with the
use of radiation therapy
following lumpectomy .
~Vinh-Hung V et al. J Natl Cancer
Inst 2004;96:115-121.

13.  “Breast conservation treatment is an appropriate
method of primary therapy for the majority of women
with Stage I and II breast cancer and is preferable
because it provides survival equivalent to total
mastectomy and axillary dissection while preserving
the breast”.
 NIH Consensus Development Conference Statement (1990)
The Era Of BCT……

14. Effect of RT after BCS on local recurrence and on Breast Ca
mortality: 15-year probabilities. EBCTCG Meta-analysis
Lancet 2005;366:2087–2106

15. Lumpectomy+ Surgical Ax Staging…..
≥ 4 Ax Nodes (+) 1-3 Ax Nodes (+) Negative Ax nodes
RT to whole breast ( ± Tumor bed
Boost), Infraclav. & Supraclav. area ,
Int. mammary 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 1.2012

16. Total 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 1.2012

18. Breast
Preserving
surgery
Optimum
Radiation
Therapy
BCT

19. Lumpectomy….
• Optimal extent of resection for treatment of EBC not clearly defined.
• Wide local excision with microscopically negative margins is preferable
to segmental mastectomy or Quadrantectomy
•Re-excision at 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 re-excision
•For larger T2-T3 tumor NACT f/b breast conservation is encouraged.

20. How to manage axillary nodes ???
 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%
“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

21. •Axelsson CK et al. Danish Breast Cancer Cooperative Group , Eur J Cancer
• Kiricuta CI, Tausch J. Cancer 1992
Adequate axillary dissection means……

22. Changing concepts in Axillary staging….
Sentinel lymphadenectomy with focused histopathologic examination
may eventually eliminate the need for standard ALND to determine that
a breast cancer patient is free of axillary metastases.
Giuliano et al, Annals of Surgery. Vol. 222, No. 3, 394-401
Veronesi U et al , Ann Surg 2010;251: 595–600
Sentinel Lymph
Node Biopsy in
Breast Cancer
Ten-Year
Results of a
Randomized
Controlled Study

23. 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

24. Sentinel nodes dissection…is it sufficient enough??
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 1·20 (95% CI 0·96—1·50; p=0·12). 8-year Kaplan-Meier
estimates for overall survival were 91·8% (95% CI 90·4—93·3) in group 1 and 90·3% (88·8—91·8) in
group 2. Treatment comparisons for disease-free survival yielded an unadjusted HR of 1·05 (95% CI
0·90—1·22; p=0·54). 8-year Kaplan-Meier estimates for disease-free survival were 82·4% (80·5—84·4) in
group 1 and 81·5% (79·6—83·4) in group 2. There were eight regional-node recurrences as first events in
group 1 and 14 in group 2 (p=0·22). 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.
NSABP-32 Trial
Krag et al, Lancet 2010 Vol.11.p 927-933

25. 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
Sentinel nodes positive…………What is next????
ACOSOG Z0011 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 therapy.
Giuliano A E et al. Annals of Surgery: 2010 - Vol 252

26. 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: 383–388, 2005

27. 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
Whelan J T et al. J Clin Oncol 29: 2011 (suppl; abstr LBA1003)
Authors conclusion : The implication of this study is that all women with
node positive disease should be treated with RNI in addition to WBI.

28. 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.

29. Before offering…
BREAST
CONSERVATIVE
THERAPY

30. ACR–ACS–CAP–SSO 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.

31. Don’t miss in surgical pathology report…
• 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

32. To Do Or Not To Do…….

33. MRM may be preferable for patients….
• Who wish to avoid radiation
• In whom removal of clinical or radiographically apparent ds results
in a suboptimal cosmetic result
• Those with diffuse positive margin can't be re-excised
•Those with diffusely suspicious microcalcifications

34. lumpectomy
t conservation therapy
mammositeAPBI
tangential
couch kick technique
sentinel node
NSABP B-06
margins
nodalstatus
EIC
boost
internal mammary
nodes
supraclavic
half beam block
electronboost
fieldmatching
single isocenter3-D CRT
interstitial
cosmesis
recurrence
divergence
conformal
multileaf
collimator
isodose
hot spot
i.e.
dose
inhomogeniety
tylectomy
Compensators
wedge
50Gy
medial breast
port technique
ELIOT
IORT
MLD
CHD
CLD
MHD
EORTC
10801
localrelapse
proneposition
heart
opp. breast
lung
skin
axillary
nodes
4-6MVphotons
IOET
Stage I & II
CO60
25-28 fraction
lungV20
TARGIT
WBIadjuvant
tamoxifen
DCIS
Overallsurvival
PTV
CTV
ALMANAC
V30
V2Gy
Toxicities
IMRT
systemictherapy
SIB
diffuse
+ve
margin
ER/PR
Her2-neu
breast
board
EBCTGG
BRCA 1/2
pregnancy
re-excision
mammogram
QUART
MRM 90̊ - 120̊ abductionisocenter
Conventional RT
in EBC

35. Treatment
volume
Indication # size/
technique
Total
dose
Comment
Whole
Breast
Routinely following BCS 2Gy or 1.8
Gy/tangents
Wedges
/dynamic
wedges to
optimize
homogeneity
45-50.4Gy Consider omission of
RT
In elderly with stage I
(ER +) and co
morbidities
Supraclav •cN2-N3 ds
•>4+LN after AD
•1-3+LN with High RF
•Node +SLN with no AD
•High risk with no dissection
•1.8-2Gy
•AP or AP-PA
45-50.4Gy May omit with 1-3
positive nodes in
selected cases
Axilla •N+ with extensive ECE
•SN+ with no dissection
•Inadequate axillary dissection
•High risk with dissection
1.8-2 Gy
AP-consider
posterior axillary
boost if suboptimal
coverage only
45-50.4 Gy Axilla may be
intentionally included
With use of “high
tangents”
Internal
Mammary
Individualized but consider for
•+Ax. Nodes with Central & Medial
quadrant lesions
•Stage III breast cancer
•+SLN in IMN chain
•+SLN in axilla with drainage to IM
on Lymphoscintigraphy
1.8-2Gy
Partially Wide
tangents or
separate IM
electron/photon
45-50.4 Gy

36. Role of Hypofractionation RT in EBC………
Result : 5yr LRR
• 50 Gy/25# - 3.6% (95% CI 2.2-5.1%)
• 41.6Gy/13# - 3.5% (95% CI 2.1-4.3%)
[Absolute diff. with 50 Gy : 0.2% (95%
CI 1.3-2.6%)]
• 39Gy/13# - 5.2% (95% CI 3.5-6.9%)
[Absolute diff. with 50Gy : 0.9% ( 95%
CI 0.8-3.7%)]Interpretation : Dose-limiting
normal tissues respond similarly
to change in radiotherapy fraction
size. 41・6 Gy in 13 fractions was
similar to the control regimen of 50
Gy in 25 fractions in terms of local-
regional tumour control and late
normal tissue effects
START A TRIAL START B TRIAL
Result : 5yr LRR
• 50Gy/25# - 3·3% (95% CI 2·2 to 4·5)
• 40Gy/15# - 2·2% (95% CI 1·3–3·1)
[Absolute diff. with 50Gy : –0·7% (95%
CI –1·7% to 0·9%)]
Interpretation : A radiation
schedule delivering 40 Gy in 15
fractions seems to offer rates of
local-regional tumour
relapse and late adverse effects at
least as favourable as the standard
schedule of 50 Gy in 25 fractions.

37. Treatment position:
• Supine, arm abducted 90̊-120̊ and externally rotated
• Breast tilt board with armrests & other immobilization devices
• lateral position- For large pendulous breasts (Institut curie)
• Prone position- For reducing dose to underlying lung , heart & contrlat. breast
( Merchant and McCormick)
How to execute Radiation therapy…..
Treatment volume :
Targets OARs
 Whole breast , Chest wall + small lung tissue Lung
 Supraclavicular fossa Heart
 Axillary nodes Opposite Breast
 Internal mammary nodes ( if indicated) Skin

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

40. 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

41. Posterior Axillary Boost Field borders
• Medial border: 1.5-2 cm lung to show in portal film
• Lateral border : Just blocks fall of across the post. Axillary fold
• Superior border: Splits the clavicle
• Superolateral border: Splits the humeral head
• Inferior border: At the same level of inferior border of Supraclav field

42. Alignment of Tangential Beam
with Chest Wall Contour…
 To make the post. edge of the tang. beam follow to the downward sloping
contour 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
 Deep ( Intrathoracic ) field border must be nondivergent & edges made
Coplanar
• Use half beam block technique
• Rotate gantry to make symmetric & align post. edge of each tangent
 Isocenter is typically placed in the center of the field

45. 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 length
in tangential fields referring to the heart contour
Kong FM et al. Int J Radiat Oncol Biol Phys
2002;54:963-971

46.  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 6%
2.5 cm 16%
3.5 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 10̊ to 15̊ laterally)
Bornstein BA et al. Int J Radiat Oncol Biol Phys 1990;18:181-187.
Lung and Heart to be spared optimally….

47. Specify your 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

48.  “Horns” at edge of sharp Linac beams produces “Hot spots” just beneath skin at
the field junction (d/t divergence of Tangential fields and Supraclavicular field into
each other.) -
SEVERE MATCHLINE FIBROSIS or RIB FRACTURE
 Methods of matching:
1. For SCV field :- Hanging Block Technique
2. For tangential field :-
Inferior Angulation
Hanging Block Technique
Rotating Beam Splitter
Couch Kick technique
3. Single Isocenter Technique
Geometric matching of Tangential and SCV
Fields…

50. Geometric matching of Tangential fields
and IMC fields…

52. 65% to 80% of breast recurrences after conservation surgery and
irradiation occur around the primary tumor site –
Strong rationale for a tumor bed boost

53.  En-face electrons
 HDR brachytherapy
 3DCRT/ IMRT/ VMAT
 IMPT
 Modulated electrons
(MERT)
Boost modalities…
Delineation of Target area
• Clinical
• Mammography
• Surgical clips – usu 5
• Ultrasonography
• CT scan
• MRI
• Per-op placement of catheters
Target Volume for Boost
•For Electrons : 20 – 30mm.
•For BT
• +/ unknown margin in EBC: 30mm.
• - ve margin : 15 mm is adequate.
•For LABC : Not defined. An area of present trials.
•Liberal margin (even extra 5 mm) will double the
CTV.
(Ref: ESTRO Recommendations, 2002)

55.  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. 372-376,2006
Seroma contouring guidelines…

56. APBI

57.  Rationale....
Primary target requiring adjuvant treatment (following lumpectomy
with negative surgical margins) is likely limited to a 1 to 2cm
boundary surrounding the lumpectomy cavity edge
 Modalities are….
 Multi-catheter interstitial brachytherapy.
 Mammosite Radiation Therapy System
 3D Conformal External Beam APBI
 Intraoperative APBI
 Patients selection criteria
APBI at a glance……

59. Multi-catheter interstitial brachytherapy
• First developed APBI technique
• Longest experience with extensive follow-up 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
6.8 Gy

60. 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
4.25 Gy
5.1 Gy
1cm

61. • Max. dose constrains to surrounding normal structure needs to be defined
Highlights of 3D Conformal External Beam APBI
• Attractive because…
1) Non invasive , 2) Homogeneous dose pattern , 3) Less toxicity
• Impact of breathing motion and set-up error on treatment accuracy
are to be investigated.

62. Targeted Intraoperative Radiotherapy (TARGIT)
TARGIT-A trial results :
• Compared TARGIT with Conventional Whole breast EBRT
• LR at 4 years was 1·2.0% (95% CI 0·53—2·71) in TARGIT &
0·95% (0·39—2·31) in EBRT (diff. between groups 0·25%,
−1·04 to 1·54; p=0·41).
• 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 EBRT delivered over several wks.
Vaidya J S et al. 2010 Lancet ,Vol.376
 INTRABEAM low voltage ( max. 50 Kv ) x-ray generator

63. Intra Operative Electron Radio Therapy
• Mobetron ( 4-12 MeV) / Novac7 (3-9 MeV)
/ Liac (4-10 MeV)
• Total dose : 21 Gy / 1 #
• Better cosmesis, Easily accessed
No delay in RT- ↓ LR ,
Better radioprotection for normal
surrounding structures
Veronesi U et al.(2008) ecancermedicalscience 2:65

64. PBI or WBI ???...still to be answered !
Randomized multi-
centric phase-III study
to compare
• Local Tumor control ,
• OS, RFS , DDFS,
• Cosmetic results
• Perceived convenience
of care in patients
• Fatigue and treatment
related symptoms
• Acute and late toxic
effects
Schema for the NSABP B-39/RTOG 0413 Trial

65. Emerging technologies……fresh stock in market!!!
Multicatheter tail-less
comfort catheter system
SAVI (strut adjusted
volume implant) applicator
Contura™ multilumen
balloon applicator
ClearPath™ multilumen
hybrid applicator
AccuBoost HDR
192Ir applicator
Xoft Axxent electronic
brachytherapy (EBT) system

66. http://l.yimg.com/bt/api/res/1.2/3C5SDC1uf
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Systemic therapy
in
Early Breast
Cancer

67. 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
•Age≥35yrs
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(1-3)
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
Endocrine
Non
responsive
NA CT CT
Goldhrisch A et al, Meeting highlights : International expert consensus on
the primary therapy for EBC 2005 .Ann Oncol 2005;16:1569-1583

68.  Age :
<35 yrs -  risk, monitor closely
 Margin status :
 Status for –ve margin not clear
 Focally Vs diffusely +ve margin
 EIC with +ve margin -   risk
 Systemic Therapy :
 RTCT : NSABP BO6
 RT Tam : NSABP B21
 Radiation Dose : Boost
 LCIS / Lobular histology
 BRCA 1-2
 Larger tumors
 Centrally located tumors
 Node-positive
 ER/PR negative
 Her 2+ tumors
Risk Factors for Locoregional Relapse

69. Surgical therapy
related
Radiation
related
Systemic
therapy related
Host related
• Surgical resection type
• Re-excision
• Orientation & length of
scar
• Closure or not
tylectomy cavity
• Separate or continuous
axillary scar
• Extent of axillary
dissection
• Amount of skin
removed
•Total does
/Fractionation/Beam
energy/
•Dose homogeneity
•Volume treated
•Type and dose of
boost
•Type of
systemic agents
used
•Timing and
sequence
relative to
radiation therapy
•Doses and
combination of
drugs
•Size and shape
of the breast
•Age
•Race
•Compliance with
care and hygiene
•Concurrent
medical illness
•Intrinsic
sensitivity to
radiation
Cosmetic outcomes and sequelae……

70. Follow up of patients treated with 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

71. •Questionnaire based survey-among practicing 60 ROs
•Nov2006-March 2008
•Median no. of Breast cancer Pts treated by each-130
•Out of these EBC-30%,LABC-50% & MBC-20%
 RESULTS FOR EBC-
•Only 46% opted for BCS
• MRM was choice in Multicentric Ds ,Lobular ca or Non compliance with Adj.RT(73%)
•75% did not opted for SLNB
•92% recommended RT after BCT & 85% of them considered Tumor Bed Boost
• None of ROs opted for Hypofractionated RT
• 20% still preferred Ax. RT after BCS in Node(-ve) EBC
• 20% advocated Radical Brachytherapy in EBC
• 67% considered treatment with Telecobalt
“Access to optimal surgical expertise , bulky tumors at
presentation, limited radiation oncology infrastructures, and lack of
expertise for the planning and treatment of RT for BCT makes
conservation difficult in Indian scenario.”
Patterns of locoregional treatment of Breast cancer
Among radiation oncologists in India : A practice survey
Budrukkar et al. JCRT 2010 Vol 6 Issue 4
Gap between evidence and practice….

72. lumpectomy
t conservation therapy
mammositeAPBI
tangential
couch kick technique
sentinel node
NSABP B-06
margins
nodalstatus
EIC
boost
internal mammary
nodes
supraclavic
half beam block
electronboost
fieldmatching
single isocenter3-D CRT
interstitial
cosmesis
recurrence
divergence
conformal
multileaf
collimator
isodose
hot spot
i.e.
dose
inhomogeniety
tylectomy
Compensators
wedge
50Gy
medial breast
port technique
ELIOT
IORT
MLD
CHD
CLD
MHD
EORTC
10801
localrelapse
proneposition
heart
opp. breast
lung
skin
axillary
nodes
4-6MVphotons
IOET
Stage I & II
CO60
25-28 fraction
lungV20
TARGIT
WBIadjuvant
tamoxifen
DCIS
Overallsurvival
PTV
CTV
ALMANAC
V30
V2Gy
Toxicities
IMRT
systemictherapy
SIB
diffuse
+ve
margin
ER/PR
Her2-neu
breast
board
EBCTGG
BRCA 1/2
pregnancy
re-excision
mammogram
QUART
MRM 90̊ - 120̊ abductionisocenter
Conclusion1.BCS followed by RT is equivalent to mastectomy for appropriately selected
patients with EBC
2.SLNB without AD may be sufficient management selected group of
EBC pts treated with BCS and adjuvant therapy
3.Outcome of BCT is dependent on execution of RT which is technically
demanding
4. Radiation Boost to primary tumor volume gives improved local
Control but minimal survival benefit
5.PBI/APBI –though results are promising , still not accepted as standard of
care and needs further evaluation
6.Systemic therapy as Neoadjuvant or adjuvant therapy results in better
outcome in terms of down staging as well as LRC
7.Close and careful monitoring is essential during follow-up period to detect
both local recurrence as well as distant metastasis

73. Thank You