Recent Advances in Breast Radiotherapy

Transcription

1 Recent Advances in Breast Radiotherapy Dr Anna Kirby Consultant Clinical Oncologist

2 2 The Royal Marsden Overview: Key innovations 1. 2D to 3D planning 2. Hypofractionation 3. Intensity modulated radiotherapy 4. Tumour bed localisation 5. Heart-sparing breast radiotherapy 6. Risk-adapted radiotherapy 7. Intra-operative radiotherapy

3 3 The Royal Marsden Overview: Key innovations 1. 2D to 3D planning 2. Hypofractionation Increasing efficacy 3. Intensity modulated radiotherapy 4. Tumour bed localisation Reducing side-effects 5. Heart-sparing breast radiotherapy 6. Risk-adapted radiotherapy 7. Intra-operative radiotherapy

4 2D to 3D planning

5 2D-planned radiotherapy Primary Beam

6 Potential for missing tumour bed

7 Potentially large normal tissue doses

8 2D vs 3D radiotherapy dose distributions Courtesy: Ellen Donovan

9 Full 3D optimisation

10 3D planning: the benefits Increases accuracy Allows optimisation of breast coverage vs normal tissue doses Reduces late side-effects including breast shrinkage, firmness, pain and rib fracture 80% of UK RT centres offer 3D dose optimisation (RCR audit 2012)

11 Hypofractionation

12 START Trial START Trial B Trial B N= Gy in 25 # (2.0Gy) 5 wks N= Gy in 15 # (2.67Gy) 3 wks N= years median follow-up

13 Trial B : Local-regional (LR) tumour relapse % of patients with no LR relapse Gy (29 / 1110) 50 Gy (36 / 1105) Cumulative hazard rate Gy Gy Years since randomisation Number at risk: Yr 0 Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr Years since randomisation Hazard Ratio (95%CI) Absolute difference at 5 yr (95%CI) 40 Gy vs. 50 Gy 0.79 ( ) -0.6% (-1.7% 0.9%)

14 Trial B: Change in breast appearance % of patients with no change in breast appearance Gy/15F (145 / 462) 50 Gy/25F (167 / 461) Years since randomisation Number Yr 0 Yr 2 Yr 5 at risk: Hazard Ratios (95%CI) Absolute difference at 5 yr (95%CI) 40 Gy vs. 50 Gy 0.83 ( ) -5.6% (-11.8% 1.2%)

15 40Gy vs. 50Gy The Royal Marsden Trial B : Late normal tissue effects PATIENT self-assessment (moderate or marked) PHYSICIAN assessment of (moderate or marked) 40Gy better 50Gy better 40Gy better 50Gy better Shrinkage Hardness Skin appearance Breast appearance Swelling Shrinkage Induration Telangiectasia Oedema Hazard Ratio (95% CI) Hazard Ratio (95% CI)

16 Standard RT Regimens are Changing Total dose (Gy) Number fractions Fraction size (Gy) Time (weeks) International Standard New UK Standard

17 Advantages of hypofractionated breast RT Reduced acute and late side-effects Trend towards greater efficacy Easier to integrate with surgery & systemic therapies More convenient for patients

18 Intensity modulated radiotherapy (IMRT)

19 Simple forward-planned IMRT: step and shoot Open Field Segmented Field

20 Simple forward-planned IMRT: step and shoot

21 Inverse-planned IMRT Pectus excavatum Internal mammary chain Bilateral breast RT

22 Volumetric modulated arc therapy

23 Tumour bed localisation

24 Tumour bed localisation Cavity visualisation scores Landis et al, IJROBP, 2007?

25 Oncoplastic surgery: scar tumour bed

26 Marker-based tumour bed localisation IMPORT HIGH Trial Planning Pack

27 Boost planning based on markers Clips Skin entry point Excision cavity IMPORT High Trial, RMH Sutton

28 Heart-sparing radiotherapy

29 Addition of RT to BCS improves local control & survival Early Breast Cancer Triallists Collaborative Group, Lancet, 2005

30 but increases non breast cancer mortality Early Breast Cancer Trialists Collaborative Group, Lancet, 2005

31 Standard tangents often result in high doses to cardiac tissues esp LAD Courtesy: Jane Dobbs

32 32 The Royal Marsden NCRI Conference, Liverpool Heart-sparing breast RT techniques Multileaf collimation (MLC) IMRT Prone Breath-hold

33 33 The Royal Marsden NCRI Conference, Liverpool UK HeartSpare Study (NIHR funded) ABC_DIBH v_dibh vs Digital spirometer Monitoring Visual Good data Reproducibility Data lacking Expensive Cost Cheap

34 34 The Royal Marsden NCRI Conference, Liverpool HeartSpare: Example of heart-sparing achieved in breath-hold Free breathing v_dibh ABC_DIBH

35 Risk-adapted radiotherapy

36 Risk-adapted radiotherapy Holland et al, Cancer 1985

37 IMPORT HIGH dose escalation study 2.4Gy 2.7Gy 3.2Gy 15 Fractions (3 weeks) Courtesy: Dr C Coles, Addenbrooke s Hospital

38 Brings together advances in planning, fractionation & localisation 3fld boost 5fld boost

39 Requires real time verification of position of tumour bed markers RT beam Cone beam imaging

40 Tumour bed clips make automated set-up possible 1 st day of RT Cone beam Planning CT Adjusted IMPORT High Trial, RMH Sutton

41 Partial breast radiotherapy

42 Partial breast irradiation techniques Intraoperative techniques Intrabeam (TARGIT) ELIOT (Italy) Post-operative techniques Mammosite (US) External beam RT (UK and US)

43 Intrabeam (TARGIT) Intra-operative RT 50kV photons via 3.2mm diam tube for 25-30mins >45yrs, eligible for BCT Mean FU 60mths, 5yr LRR 1.7% Vaidya et al, IJROBP 2011

44 Mammosite Post-operative Balloon 30% seroma rate, 10% infection rate, 90% good cosmesis at med FU of 72 mths Vicini IJROBP 2011

45 External beam partial breast irradiation Treats 25mm margin around tumour bed Full path report available Coles &Yarnold, UK

46 Partial breast irradiation Currently available in trial setting only Awaiting long-term follow-up of a number of studies Likely to be available to limited subgroups of women in the medium term

47 47 The Royal Marsden Change Presentation title and date in Footer dd.mm.yyyy Advances in breast RT: what do these mean for your patients? Most women can be treated in 3-4 weeks with reduced risk of late-side effects due to Homogeneous 3D-doses Reduced total dose to normal tissues Use of heart-sparing techniques Accuracy of treatment is within mm due to 3D anatomical information Tumour bed markers

48 The future of breast radiotherapy Ongoing studies in risk-adapted radiotherapy aim to individualise treatment further Improved imaging techniques will help guide use of nodal irradiation Likely to be delivering less RT in future Either less tissue treated Or no RT Indications for intra-operative radiotherapy likely to increase