馬偕紀念醫院新竹分院 乳癌放射治療指引 修訂 四版

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1 馬偕紀念醫院新竹分院 乳癌放射治療指引 修訂 四版

2 前言 新竹馬偕醫院放射腫瘤科藉由跨院聯合會議機制進行討論, 以制定符合現狀之 乳癌放射治療指引 本院乳癌放射治療指引的建立, 係參考國內外文獻報告及台北總院臨床指引, 彙整而成 本院乳癌分期採用美國 TNM 7 th edition 癌症分期系統, 符合臨床的需求 本院乳癌放射治療流程, 以實證醫學方式並參考國內外醫學中心治療指引, 彙集而成 乳癌放射治療指引 的目的, 為提供醫師在臨床處理之建議 醫師應秉其專業, 解釋治療之損益, 更要以病人及家屬的意願與選擇為主, 讓病人獲得最恰當的治療

3 AJCC 2010 cancer stage of breast ca: T0 No evidence of primary tumor Tis Carcinoma in situ Tis (DCIS) Ductal carcinoma in situ Tis (LCIS) Lobular carcinoma in situ Tis (Paget's) Paget's disease of the nipple with no tumor Note: Paget's disease associated with a tumor is classified according to the size of the tumor. T1 Tumor 2 cm or less in greatest dimension T1mic Microinvasion 0.1 cm or less in greatest dimension T1a Tumor more than 0.1 cm but not more than 0.5 cm in greatest dimension T1b Tumor more than 0.5 cm but not more than 1 cm in greatest dimension T1c More than 1 cm but not more than 2 cm in greatest dimension T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension T3 Tumor more than 5 cm in greatest dimension T4 Tumor of any size with direct extension to chest wall or skin, only as described below

4 T4a Extension to chest wall, not including pectoralis muscle T4b Edema (including peau d'orange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast T4c Both (T4a and T4b) T4d Inflammatory carcinoma Regional Lymph Nodes Clinical staging Pathologic staging cn0 No lymph node metastases pn0 No lymph node metastases cn1 Movable ipsilateral axillary pn1mi Micrometastases (> 0.2mm but <= 2.0 mm) lymph nodes pn1a 1-3 axillary lymph nodes (at least 1 > 2.0mm) pn1b Metastases in IM nodes (micrometastases, or macrometastases detected by SLN biopsy but not clinically detected) pn1c 1-3 axillary lymph nodes and metastases in IM nodes (micrometastases, or macromets detected by SLN but not clinically detected) cn2a Ipsilateral axillary lymph nodes pn2a 4-9 axillary lymph nodes (at least 1 > 2.0 fixed or matted mm) cn2b Clinically detected internal mammary nodes in the absence pn2b Metastases in clinically detected IM nodes in the absence of axillary lymph nodes of axillary lymph node metastases cn3a Infraclavicular lymph nodes pn3a 10 or more axillary lymph nodes (at least 1 > (level III) 2.0 mm); or infraclavicular (level III) lymph nodes cn3b Clinically apparent internal pn3b Metastases in clinically detected IM nodes in mammary nodes with axillary lymph node involvement the presence of positive axillary nodes; or microscopic IM nodes and more than 3 axillary lymph nodes

5 cn3c Supraclavicular lymph nodes pn3c Supraclavicular lymph nodes M0 - none cm0(i+) - no clinical or radiographic evidence of distant metastases, but tumor cells detected in circulating blood, bone marrow, or other tissues (e.g. prophylactically removed ovaries), 0.2 mm, in a patient without symptoms or signs of metastases. M1 - distant detectable metastases; or histologically proven > 0.2 mm Stage 0 Tis N0 M0 Stage IIIA T0 N2 M0 Stage IA T1* N0 M0 T1* N2 M0 Stage IB T0 N1mi M0 T2 N2 M0 T1* N1mi M0 T3 N1 M0 Stage IIA T0 N1** M0 T3 N2 M0 T1* N1** M0 Stage IIIB T4 N0 M0 T2 N0 M0 T4 N1 M0 Stage IIB T2 N1 M0 T4 N2 M0 T3 N0 M0 Stage IIIC Any T N3 M0 Stage IV Any T Any N M1

6 Breast cancer radiotherapy recommendation Adjuvant radiotherapy stage Tis N0M0 (DCIS) Stage I, IIA, IIB T3N1M0 Stage IIA, IIB T3N1M0 (with Neoadjuvant) Stage IIIA, IIIB, IIIC treatment Post Lumpectomy without axillary LN dissection whole breast irradiation(wb)+/- scar boost (age<50, margin close or +, LVSI+, grade 2-3, tumor size >=2cm) Post Lumpectomy with surgical axillary stage 1. N0: Whole breast +- scar boost 2. N1(LN:1): Whole breast +- sacr boost, consider SCF and ICF 3. N1(LN:2-3): Whole breast +- sacr boost, strong consider SCF and ICF; consider IMN 4. N2: Whole breast +- scar boost + SCF+ICF+ scar boost; Strongly consider IMN Post MRM and axillary LN dissection 1. N0, margin close: Consider Chest wall 2. N0, margin + or T> 5cm: Consider Chest wall +/- (SCF+ICF) ; consider IMN 3. N1: Strongly consider Chest wall+ SCF+ ICF; Strongly consider IMN 4. N2: Chest wall+ SCF+ICF; Strongly consider IMN Post Lumpectomy with surgical axillary stage 1. N0: Whole breast +- scar boost 2. N1(LN:1): Whole breast +- sacr boost, consider SCF and ICF 3. N1(LN:2-3): Whole breast +- sacr boost, strong consider SCF and ICF; consider IMN 4. >N2: Whole breast +- scar boost + SCF(axillary LN level II, III)+ scar boost; Strongly consider IMN Post MRM and axillary LN dissection 1. N0, margin clear, T 5cm: no RT 2. N0, margin close: Chest wall 3. N0, margin + or T> 5cm: Chest wall+-(scf+axilla) ; consider IMN 4. N1: Chest wall+ SCF+ upper axilla; consider IMN 5. N2: Chest wall+ SCF, axilla; Strongly consider IMN Neoadjuvant chemotherapy with axillary LN dissection + lumpectomy or MRM

7 Post operative radiotherapy based on prechemotherapy tumor characteristics Target delineation: (whole breast, chest wall, axilla level I,II,III, SCF, IMN) Cranial Caudal Anterior Posterior Medial Lateral Whole breast Breast+ chest wall Chest wall SCF Clinical Reference + Second rib insertion Clinical reference + loss of CT apparent breast Skin Excludes pectoralis muscles, chestwall muscles, ribs Clinical Reference + mid axillary line typically, excludes latissimus (Lat.) dorsi m. Same Same Same Includes Same pectoralis muscles, chestwall muscles, ribs Caudal border of the clavicle head Clinical reference+ loss of CT apparent contralateral breast Same Rib-pleural interface. (Includes pectoralis muscles, chestwall muscles, ribs) Clinical Reference/ mid axillary line typically, excludes lattismus dorsi m Caudal to Junction of Sternocleido Anterior Cranial: the brachioceph.- mastoid aspect of the lateral cricoid axillary vns./ (SCM) scalene m. edge of cartilage caudal edge muscle (m.) SCM m. clavicle head Caudal: junction 1st rib-clavicle Sternalrib junction Same Sternal-rib junction Excludes thyroid and trachea

8 Axilla Axillary Pectoralis Plane Anterior Medial Lateral level I vessels (Pec.) major defined by: surface of border of border of cross muscle insert anterior subscapularis lat. dorsi Pec. lateral into ribs surface of m. m. minor m. edge of Pec. Maj. Pec. m. and Lat. Dorsi m. Axilla Axillary Axillary Anterior Ribs and Lateral Medial level II vessels vessels cross surface Pec. intercostal border of border of cross lateral edge muscles Pec. Minor Pec. medial of Pec. m. edge of Pec. Axilla Pec. Axillary Posterior Ribs and Medial Thoracic level vessels cross surface Pec. intercostal border of inlet III insert on medial edge Major m. muscles Pec. Minor cricoid of Pec. m. IMN Superior Cranial aspect of aspect of the the 4th rib medial 1st rib. ICF: Axilla level II, III Radiation Dose CTV 50 Gy given as Gy fraction +/- scar boost (surgical tumor bed) Boost LN with ECE: 10 Gy ( Gy fraction) Scar boost: 10~16Gy in 2Gy fraction size (by electron or photon) Patient Set-up: 1. Patient in supine position with mold placed underneath, raise hand above head over

9 lesion side, head turn away from lesion side. 2. Markers will be placed on post-operative scars, mid-axillary line and boundaries of normal breast. 3. Non-contrast enhanced CT simulation will be arranged.

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