Accelerated Parial Breast Irradiation- Who Benefits From APBI?

1. Who Can Benefit From APBI & The Changing Treatment Landscape Joe L. Meadows, M.S. Medical Physicist The Lacks Cancer Center Saint Mary’s Health Care Grand Rapids, MI Joe Meadows M.S. St Mary’s March 2009 Joe Meadows M.S. St Mary’s March 2009

4. Joe Meadows M.S. St Mary’s March 2009 Prospective Randomized Trials: BCT vs.Mastectomy

5. Joe Meadows M.S. St Mary’s March 2009 Prospective Randomized Trials: Lumpectomy +/- Radiation Therapy

7. Benefit of Post Op Treatment Doctors in some parts of the United States may be more old-fashioned and less likely to offer lumpectomy with radiation as an option for their patients, particularly their older patients . Such doctors may urge mastectomy , even for women who should be offered the choice. But recent research has shown that women 75 or older who get radiation after lumpectomy are more likely to live longer and remain free of breast cancer longer than women who do not get radiation. http://www.breastcancer.org/treatment/surgery/lumpectomy/index.jsp Joe Meadows M.S. St Mary’s March 2009

10. Breast Conserving Therapy + = BCT candidate Joe Meadows M.S. St Mary’s March 2009 A. Tumor B. Lumpectomy specimen

11. Whole Breast or Partial? For patients with node-negative breast cancer who undergo breast conserving surgery (BCS), RT to the whole breast is standard adjuvant local treatment. Clearly demonstrated in randomized trials to provide local control and survival comparable to mastectomy . h ttp://www.medscape.com/viewprogram/8355

17. National Protocol 127 Pages !! Easy Reading

18. National Protocol

20. Patient Selection Criteria NØ; N1 (1-3 nodes) NØ NØ Nodal status Negative microscopic surgical margins of excision by NSABP definition Negative microscopic surgical margins of excision Negative microscopic surgical margins of excision Surgical margins < 3cm < 3cm < 3cm Tumor size Invasive adenocarcinoma or DCIS Invasive ductal carcinoma or DCIS Infiltrating ductal carcinoma Diagnosis > 18 > 45 > 50 Age *NSABP B39 - RTOG 0413 Eligibility Criteria ASBS Recommendations (Updated December 2005) ABS Recommendations (Updated February 2007)

23. Dr.F.Vicini Beaumont Hospital WBH Data: Matched Pair Analysis 12 Yr Actuarial Outcome - APBI vs. WBRT 0.1 96% 99% Cosmesis (excellent/good) 0.6 2 % 2 % Clonally Distinct / Elsewhere 0.5 4 % 5 % IBTR 0.1 67 % 75 % 5 yr DFS after IBTR 0.3 93 % 95 % Cause-Specific Survival 0.4 87 % 91 % Freedom From Failure 0.08 90 % 95 % Distant Metastases Free Survival 0.3 0.5 % 2 % Regional Nodal Failure 0.2 8 % 6 % Contralateral Failure 0.6 2 % 3 % Clonally Related / TRMM p WBRT (n=199) APBI (n=199) 12 Year Outcome Measure

24. APBI Criteria 3-Dimensional rendering of applicator surface Tissue Conformance- <10% air Skin Spacing- Min 5mm to skin Balloon Diameter & Symmetry- <2mm

29. APBI - Mammosite  Various balloon shapes/sizes offer ability to implant a broad range of cavity shapes/volumes. 5 – 6 cm Sphere 4 x 6 cm Ellipsoidal 4 – 5 cm Sphere Balloon Configuration

43. Published APBI Results - All APBI Techniques - Dr.F.Vicini Beaumont Hospital Technique # Series # Patients Follow-Up (Range) % IBTR (Range) Interstitial 14 1166 27-113 0-9% Mammosite 12 3332 2-66 0-6% 3D Conformal 3D Conformal 7 367 10-36 0-2% Totals Totals 33 4865 2-113 0-9%