ASTRO Refresher Course 2016 Breast Cancer
|
|
- Amie Atkinson
- 6 years ago
- Views:
Transcription
1 ASTRO Refresher Course 2016 Breast Cancer Jennifer R. Bellon, M.D. Dana-Farber Cancer Institute Associate Professor of Radiation Oncology Harvard Medical School
2 I have no relevant conflicts of interest
3 Breast Conservation for Invasive Disease Anatomy Selection for BCT and modern outcomes Substituting hormonal therapy for RT Shortening the RT course Update on hypofractionation Accelerated Partial Breast Irradiation
4 Outline (continued) Management of the regional nodes Axillary dissection with a positive sentinel node RT fields (SCV/IM) PMRT RT after preoperative systemic therapy Update on DCIS
5 Axillary nodes IM nodes
6 Imaging Selection of Patients for BCT U/S, spot compression for densities Magnification views for calcifications MRI (selected cases only) Tissue diagnosis Core biopsy (not FNA) Excisional biopsy if core biopsy not feasible Breast-conserving surgery Careful evaluation of margins Post-excision mammogram for residual Ca++
7 Use of Breast MRI at Diagnosis Not Established Fewer re-excisions Decreased LR Improved survival Established Finds multicentric dx More delays More biopsies Increased costs More mastectomies Houssami Ann Surg 2013 Turnbull Lancet 2010
8 Selection of Patients for BCT Contraindications: Multicentric disease Prior RT Pregnancy Positive margins (in breast tissue)? Collagen vascular disease BRCA 1/2 mutation carriers future risk Impact of biologic subtype ACOSOG Z11102 RTOG 1014 What constitutes an adequate margin?
9 Reduction in Local Recurrence with RT CS CS + RT Reduction NSABP B-06 36% 12% 67% Uppsala-Orebro 24% 9% 63% Ontario 35% 11% 69% Milan 24% 6% 75% Swedish 14% 4% 71%
10 EBCTCG: Impact of Radiation on LRR N=10801 in 17 randomized trials EBCTCG Lancet (9804):
11 How Are We Doing? Local recurrence <5% at 10 years Improved imaging More detailed pathologic examination of the specimen Improved systemic therapy Both improves LR, and also makes LR more important (by controlling micrometastatic disease) Heterogeneity of outcomes by subtype
12 Subtype is Prognostic for LR No herceptin HER2 (No Herceptin) Triple - Lum B Lum A Lum-HER2 Arvold N et al. JCO 2011; 29(29)
13 Meta-Analysis of LRR by Subtype N=12,592 BCT 57% Mastectomy 43% RT in all BCT patients and 44% of mastectomy patients Chemotherapy, 48% Herceptin in HER2-positive patients, 6% Lowery et al. Breast Ca Res Treat 2012; 133:
14 Meta-Analysis: LRR after BCT RR 0.49 Lowery et al. Breast Ca Res Treat 2012; 133:
15 Meta-Analysis: LRR After Mastectomy RR 0.66 Lowery et al. Breast Ca Res Treat 2012; 133:
16 BCT vs. Mastectomy Retrospective series from Alberta N =768; BCT, MRM or MRM+RT Higher-risk pts had MRM or MRM+RT LRR at 5 years BCT 6% MRM 15% MRM+RT 13% MVA: MRM, LVI and nodal positivity predicted LRR; chemo protective Abdulkarim et al. JCO 2011; 29
17 LRR in T1/T2, N0 Subset (No RT after MRM; 35% chemotherapy) 96% 90% T1/T2, N0 unmatched P=0.022 T1/T2, N0 matched for tumor size P=0.039 Abdulkarim et al. JCO 2011; 29
18 Wider Margins for TNBC? Retrospective review; n=535 Margins <2 mm: 71 patients Margins >2 mm: 464 patients Median follow-up 84 months; 84% received chemotherapy Cumulative incidence of LR at 60 months 4.7% for close margins 3.7% for wide margins; p=ns Pilewskie M et al. Ann Surg Oncol 2014; 21(4)
19 TNBC: Is BCT Appropriate? Comfort in these results, despite selection bias BCT remains standard treatment in otherwise appropriate patients Likely biology, not extent of surgery, is the driving factor Raises question of RT for high-risk node negative TNBC after mastectomy
20 Margins
21 Goals of Margin Evaluation To identify patients more likely to have a large residual tumor burden that can t be controlled by modern systemic therapy and RT need re-excision or mastectomy
22 Why not just re-excise? Extent of excision most important determinant of cosmetic outcome Re-excisions associated with: - Patient anxiety - Worse cosmetic outcome - Morbidity - Cost - Patients opting for mastectomy
23 Margins Meta-Analysis (Basis for ASTRO-SSO Consensus) 33 studies, invasive cancer, N = 28,162; 1506 LRs Follow up: 79 months (range: ) Series reports used not individual patient data Does not apply to: no RT, neoadjuvant, APBI, pure DCIS Houssami N, et al. Ann Surg Oncol 2014; 21:
24 Margins Meta-Analysis Margins and LR (adjusted for length of FU) OR 95% CI p-value Margin status Negative 1.0 <.001 Positive/Close Margin status Negative 1.0 Close Positive < Increased local recurrence rate associated with positive margins not nullified by radiation boost, systemic therapy, or favorable biology Houssami N, et al. Ann Surg Oncol 2014; 21:
25 Margins Meta-Analysis Relationship Between LR and Margin Threshold Distance # studies #LRs/#subjects OR* 95% CI 1 mm 6 235/ mm / mm 3 103/ * Adjusted for length of FU p (association) = 0.90 p (trend) = 0.58 Houssami N, et al. Ann Surg Oncol 2014; 21:
26 ASTRO-SSO Margins Consensus: Summary Negative margins (no ink on tumor) optimizes local control Positive margin associated with at least a 2-fold increased risk of LR Not nullified by the boost, systemic therapy, or favorable biology Wider margin widths do not significantly improve local control The routine practice of obtaining margins more widely clear than no ink on tumor is not indicated J Clin Oncol May 10;32(14):
27 Boost
28 EORTC Boost Stage I/II; n=5318 Microscopic complete resection For invasive disease only Randomization: 50 Gy whole breast 50 Gy whole breast + 16 Gy boost Median follow-up 17.2 years Bartelink H, et al. Lancet Oncol Jan;16(1):47-56
29 EORTC Boost: 20-Year Results Ipsilateral breast tumor recurrence as a first event 16.4% vs 12.0% HR 0.65; 99% CI , p< No difference in distant metastasesfree survival or overall survival Severe fibrosis 5.2% vs 1.8%, p< Any fibrosis 71.4% vs 57.2%. P<0.001 Bartelink H, et al. Lancet Oncol Jan;16(1):47-56
30 Local Recurrence by Age < >60 Bartelink H, et al. Lancet Oncol Jan;16(1):47-56
31 Omission of Radiation
32 NSABP B-21: BCT in Tumors < 1.0 cm N=1009, T1a,1b N0 Randomized to RT + placebo, Tam, Tam + RT Only 54-59% known to be ER+ RT 50 Gy whole breast; boost optional (20%) Fisher et al, J Clin Oncol Oct 15;20(20):4141-9
33 IBTR by Treatment Arm 17% 9% 3% All comparisons p<0.05 Bernard Fisher et al. JCO 2002;20:
34 Omission of Radiation: CALGB 9343 Randomized trial of tamoxifen alone or tam with radiation in women over 70 Axillary dissection discouraged 37% dissection; 63% no axillary surgery All clinically node negative RT 45 Gy whole breast + 14 Gy boost Median follow-up 12.6 years Hughes KS et al JCO 2013, 45: 2615
35 CALGB 9343: Results at 10 Years N LRR Free Survival (%) DM Free Survival (%) Overall Survival (%) Mastectomy Free Survival (%) TAM TAM + RT * * P<.001; HR 0.18 Not able to assess subtleties in risk groups (LVI, grade)) Hughes KS et al JCO 2013, 45: 2615
36 PRIME II: RT + Hormonal therapy vs Hormonal therapy alone RT + hormonal therapy vs hormonal therapy alone Age greater than 65 < 3.0 cm, N0 HR positive Margins >1 mm (CALGB no ink on tumor) Grade 3 or LVI permitted (not both) Kunkler I, Lancet Oncol Mar;16(3):266-73
37 PRIME II: 5-year Results RT NO RT P IBTR (%) DM (%) NS OS (%) NS N=1326 Kunkler I, Lancet Oncol Mar;16(3):266-73
38 Fyles, A. et al. NEJM 2004;351: Omission of Radiation Princess Margaret Hospital Phase III, randomized trial RT + TAM vs TAM alone Eligibility 50 and older T1, T2 Path node negative if younger than 65 (clinically node negative if older than 65)
39 Fyles, A. et al. NEJM 2004;351: PMH Stratification Tumor size (<2.0 cm, >2.0 cm) ER (positive, negative or unknown) Participating center Method of determining axillary status in women over 65 (clinical or surgical)
40 Patient Characteristics (n=769) Fyles, A. et al. NEJM 2004;351:
41 Patient Characteristics (n=769) Fyles, A. et al. NEJM 2004;351:
42 Patient Characteristics (n=769) Fyles, A. et al. NEJM 2004;351:
43 Fyles, A. et al. NEJM 2004;351: Cumulative Incidence of Local Relapse PMH: Time to Local Recurrence 8 yr LR: 17.6% vs 3.5%
44 Disease-free Survival. Disease-Free Survival No difference in OS 93.2% vs 92.8% Fyles AW et al. N Engl J Med 2004;351:
45 RT for Luminal A Disease? Subset of 304 patients Approximation of intrinsic molecular subtyping ER, PR, Ki-67, Her2, EGFR and CK5/6 Luminal A (+/+/-, Ki67<14%) and grade I/II; n=114) Luminal B (+/+/-, Ki67>14%; n=82) Liu et al JCO, 33 (18), 2015
46 Response to RT by Subtype Luminal A Luminal B "unfavorable subtypes" Liu et al JCO, 33 (18), 2015
47 Three Hormonal Therapy Alone Prospective Single-Arm Trials Premise: There exists a subset of patients with early-stage disease with such a low likelihood of recurrence such that radiation can be safely omitted
48 PRECISION (DFCI) Age Unifocal, <2.0 cm Node negative (path); N0i+ permitted ER positive, PR positive, HER2 negative Grade I/II Luminal A by PAM50 Eligible and willing to receive endocrine therapy Accrual goal: 345 ClinicalTrials.gov NCT
49 LUMINA (Ontario Clinical Oncology Group) T1N0 Grade I or II and Ki67 < 13.25% (luminal A) Age >55 Margins > 1 mm No lobular cancers, No EIC Accrual goal: 500 ClinicalTrials.gov NCT
50 Individualized Decisions for Endocrine Therapy Alone (IDEA) Multicenter, led by University of Michigan T1N0 (i+ allowed) ER+/PR+/HER2 neg Age Oncotype <18 Minimum 5 years of endocrine therapy Accrual goal: 200 ClinicalTrials.Gov NCT
51 Hypofractionation
52 Ontario Clinical Oncology Group Trial 1234 patients randomized to: 50 Gy/2 Gy fx/35 days vs 42.5 Gy/16 fx/22 days T1 T2 tumors; all node negative Large breasted women excluded (separation > 25 cm) Non-inferiority with 80% power to rule out 5% increase in local recurrence Whelan et al, J Natl Cancer Inst 2002, 94(15):
53 Whelan et al: Results Median follow-up: 12 years Tam : 41% Chemo: 11% Whelan et al NEJM 362 (6), 2010
54 Long-term Toxicity Late Effects of Radiation No difference in skin/subcutaneous toxicities Whelan TJ, NEJM 2010; 362:513-20
55 Global Cosmetic Outcome, Assessed According to the EORTC Scale. Long Term Cosmetic Results No difference in long-term cosmetic result Whelan TJ et al. N Engl J Med 2010;362:
56 UK Start B N=2215 Median follow-up: 9.9 years Standard Arm: 2 Gy per fraction 25 fractions/5 weeks Experimental arm: 2.66 Gy per fraction 15 fractions/3 weeks Haviland JS et al. Lancet Oncology (14), 2013
57 Start B: Cumulative Incidence LRR LRR HR.77 ( ); p= Gy 40 Gy Time from randomisation (years) Haviland JS et al. Lancet Oncology (14), 2013
58 Start B: Marked/Moderate Cosmetic Defect % of patients with no moderate / marked effect HR.77 ( ) 40 Gy 50 Gy Time from randomisation (years) Haviland JS et al. Lancet Oncology (14), 2013
59 Use of Hypofractionation by Institution (October, December, 2013) Total: 31% Fig. 1. Rates of hypofractionation use by institution for patients with T1-2, N0 tumors treated with lumpectomy and whole-breast radiation therapy (n=913). Jagsi et al, IJROBP Volume 90, Issue 5, 2014,
60 Hypofrac vs Conventional: MDACC 50 Gy/25 fx Gy/7 fx (n=149) Vs Gy/ Gy/4-5 fx (n=138) Eligibility 40 or older Stage 0-2 Breast only radiation Shaitelman et al, JAMA Oncol. 2015;1(7):
61 Primary Objectives MD-reported acute and 6-month toxicity NCI-CTC Patient reported QOL at 6 months Functional assessment of cancer therapy for patients with breast cancer (FACT-B) Shaitelman et al, JAMA Oncol. 2015;1(7):
62 Key Patient/Treatment Characteristics 79% C cup or larger 25% sep > % overweight or obese Prone or supine permitted Multiple subfields encouraged to maximize homogeneity 75% dmax < 107.7% Shaitelman et al, JAMA Oncol. 2015;1(7):
63 Max MD-reported acute toxic effect Not significant: Wound complications Breast infection Skin ulceration Seroma UE edema Shaitelman et al, JAMA Oncol. 2015;1(7):
64 6-months Results Physician-reported fatigue: 0% HF vs 6% CF (p=0.01) Patient reported lack of energy: 23% HF vs 39% CF (p=<0.001) Trouble meeting family needs: 3% HF vs 9% CF (p=0.01) Shaitelman et al, JAMA Oncol. 2015;1(7):
65 Predictors of Lack of Energy at 6 Months n OR p Randomization Conventional Hypofrac <0.001 Age and older BMI < > Tumor behavior Invasive 69 1 Non-invasive Shaitelman et al, JAMA Oncol. 2015;1(7):
66 Predictors of Lack of Energy at 6 Months n OR p Randomization Conventional Hypofrac <0.001 Age and older BMI < > Tumor behavior Invasive 69 1 Non-invasive Shaitelman et al, JAMA Oncol. 2015;1(7):
67 Hypofractionation Hypofractionation is rapidly becoming standard of care for most women treated with breast conserving surgery and whole breast radiation Note only is long-term LR similar, but now we have convincing data that short-term toxicity and QOL is improved, and long-term toxicity isn't compromised
68 Unanswered Questions Is the biology the same in all subgroups? Triple negative? DCIS? What is the optimal dose/fractionation/boost? What about chest wall/nodal irradiation? Brachial plexopathy? Lymphedema???
69 Other Hypofractionation Trials IMPORT High (UK) 2.4 Gy x 15 fx (integrated boost) 2.67 Gy x 15 fx (sequential boost) Accrual goal 840 FAST (UK) 2 Gy x 25 fx 5.7 Gy x 5 fx 6 Gy x 5 fx All in 5 weeks
70 TROG Trial for DCIS Accrual goal 1600 Conventional fractionation, no boost 50 Gy, 25 fractions Conventional fractionation, boost 50 Gy, 25 fractions + 16 Gy, 8 fractions Hypofractionated, no boost 42.5 Gy, 16 fractions Hypofractionated, boost 42.5 Gy 16 fractions + 16 Gy, 8 fractions
71 RTOG 1005 Randomized non-inferiority trial Conventional fractionation (2 Gy x 25 fx) with sequential boost VS Hypofractionation (2.67 x 15 fx) with concomitant boost Closed 6/20/14 Over-accrued 2354 ClinicalTrials.gov NCT
72 Accelerated Partial Breast Irradiation
73 Accelerated Partial Breast Irradiation Starting to see maturation of the modern randomized trials GEC-ESTRO Interstitial brachytherapy Targit A IORT photons ELIOT IORT electrons RAPID External beam photons
74 GEC-ESTRO Prospective, randomized non-inferiority trial 3% non-inferiority margin Primary endpoint: IBTR Primary < 3.0 cm, N0 (micromets allowed) Randomization 50 Gy/25 fx whole breast Insterstitial brachytherapy HDR: 4 Gy x 8 or 4.3 Gy x 7 PDR: 0.6 Gy-0.8 Gy to 50 Gy Strnad, et al Lancet 2015 epub ahead of print
75 Strnad, et al Lancet 2015 epub ahead of print Patient Characteristics APBI (n=633) WBI (n=551) P-value Age (years, median) 62 (40-92) 62 (40-85) 0.86 Menopausal status pre 108 (17%) 92 (17%) post 525 (83%) 459 (83%) 0.93 Tumor size (mm, range) 12 (9-30) 12 (9-30) 0.19 Margin (mm, range) 8 (2-40) 7 (2-25) 0.39 Grade (39%) 217 (39%) (50%) 288 (52%) (9%) 42 (8%) Systemic Therapy Yes 572 (90%) 505 (92%) No 59 (9%) 46 (8%) 0.63
76 Strnad V, et al Lancet 2015 epub ahead of print Ipsilateral Breast Recurrence
77 Disease-Free Survival Strnad, et al Lancet 2015 epub ahead of print
78 Results still early GEC-ESTRO Late recurrences seen with luminal A disease Long-term toxicity and cosmetic outcome Are these patients that don t need treatment? Interstitial will likely not be routinely used in the majority of centers in the US Strnad, et al Lancet 2015 epub ahead of print
79 Targeted Intraoperative RT (TARGIT) 50 kv x-rays N= 3451 Multi-institutional Accrued Age >45 Unifocal External beam whole breast 40 Gy-5 Gy in fractions +/- boost (10-16 Gy in 5-8 fractions) IORT: 20 Gy at surface *If high risk, add Gy whole breast (lobular carcinoma, EIC, <1 mm margin) Can be at time of surgery, or delayed Vaidya JS et al, Lancet (9917):603-13
80 TARGIT: Low Risk Patients Median age: 63 <2.0 cm 86% Grade I/II 84% Node negative 83% Hormonal therapy 66% Chemotherapy 12% Vaidya JS et al, Lancet (9917):603-13
81 Follow-up: Median: 29 months TARGIT: Results minimum of 4 years: 2020 patients minimum of 5 years: 1222 patients 5-year IBTR: 3.3% TARGIT vs 1.3% WBRT HR 2.07 (95% CI ) Within pre-specified non-inferiority margin (2.5%) Vaidya JS et al, Lancet epub ahead of print Vaidya JS et al, Lancet (9917):603-13
82 TARGIT: Results Concurrent with lumpectomy: 2.1% TARGIT vs 1.1% WBRT (p=0.31) Delayed after lumpectomy 5.4% vs 1.7% (p=0.069) Overall breast cancer mortality similar 2.6% vs 1.9% (p=0.56) Decreased non-breast cancer deaths 1.4% vs 3.5% (p=0.008) Vaidya JS et al, Lancet epub ahead of print Vaidya JS et al, Lancet (9917):603-13
83 Intraoperative Radiotherapy versus External Radiotherapy for Early Breast Cancer (ELIOT) EORTC randomized trial of WBRT and IORT (electrons) IORT: 21 Gy x 1 WBRT: 2 Gy x 25 WB + 2 Gy x 5 boost Primary endpoint: IBTR Equivalence trial with a 7.5% equivalence margin Veronesi U, Lancet Oncol 2013 Dec;14(13):
84 Patient Characteristics Veronesi U, Lancet Oncology 14 (13), 2013 Veronesi U, Lancet Oncol 2013 Dec;14(13):
85 Patient Characteristics Veronesi U, Lancet Oncology 14 (13), 2013 Veronesi U, Lancet Oncol 2013 Dec;14(13):
86 Patient Characteristics Veronesi U, Lancet Oncology 14 (13), 2013 Veronesi U, Lancet Oncol 2013 Dec;14(13):
87 ELIOT: Results N = 1305 Median follow-up 5.8 years IBTR WB: 0.4% IORT: 4.4 % (HR 9.3; 95% CI 3.3 to 26.3) Veronesi U, Lancet Oncol 2013 Dec;14(13):
88 IBTR Overall Survival Veronesi U, Lancet Oncol Veronesi 2013 Dec;14(13): U, Lancet Oncology 14 (13), 2013
89 Predictors of Recurrence in IORT Group Factor IBTR P-value Path Size (cm) < to > P=0.006 Grade P= Subtype Luminal A 1.4 Luminal B 4.9 Her2 pos 5.9 Triple negative 18.9 P=0.001 Veronesi U U, et al, Lancet Oncology (13), 2013 Dec;14(13):
90 RAPID: WB vs APBI N=2135 Median follow-up: 36 months 3d CRT APBI (38.5/10 fx BID) VS WB (42.5 in 16 fx or 50 in 25 fx +/- boost) Olivotto, IA, et al. J Clin Oncol (32)
91 Three and Five Year Toxicity and Cosmetic Assessments Olivotto, IA, et al. J Clin Oncol (32) Olivotto, IA, et al. J Clin Oncol (32)
92 Three and Five-year Cosmetic Results Olivotto, Olivotto, IA, et al. IA, J et Clin al. Oncol J Clin 31(32) Oncol (32)
93 Late Radiation Toxicity Olivotto, IA, Olivotto, et al. J IA, Clin et al. Oncol J 31(32) Clin Oncol (32)
94 ASTRO Consensus Statement Suitable* Cautionary** Unadvisable*** Age > <50 Size <2 cm cm >3.0 cm LVI Negative Limited Extensive Margin >2 mm Close; <2 mm Positive Histology Ductal Lobular DCIS Not pure DCIS DCIS <3 cm DCIS >3 cm Nodes N0, N0i + Node positive ER Positive Negative * Acceptable outside of a clinical trial ** Caution and concern in the use of APBI *** Not warranted outside of a study Smith BD et al. IJROBP 74(4), 2009
95 Modern Phase III Trials of PBI vs WBRT Institution/Trial Target (yrs of accrual) Control Arm Experimental Arm European Institute of Oncology ELIOT 1200 ( ) WBI (50 Gy in 25 fx) ± 10 Gy Boost IORT (21 Gy in 1 fx, using electrons up to 9 MeV) TARGIT-A 3451 ( ) WBI Gy ± Gy boost IORT (20 Gy in 1 fx, low energy -rays) *NSABP B 39/RTOG 0413 Closed to accrual 4/13; n= Gy WBI ± Gy Boost (1) MIB (34 Gy in 10 fx), or (2) MammoSite (34 Gy in 10 fx) or (3) 3D-CRT (38.5 Gy in 10 fx) French SHARE *Medical Research Council UK IMPORT LOW *Ontario Clinical Oncology Group- Canadian Trial RAPID 1170 ( ) WBI (50 Gy in 25 fx) + 16 Gy Boost WBI (40 Gy in 15 fx; or 42.5 in 16 fx) 1935 ( ) WB 2.67Gy X (2006-7/2011) WBI ± 10 Gy boost: (1) 42.5 Gy in 16 fx for small breasts or (2) 50 Gy in 25 fx for large breasts 3d-CRT (40 Gy in 10 fx, BID) (1) WB 2.4Gy X 15 (2) PB 2.67Gy X 15 (3) PB only 2.67Gy X 15 3D CRT only (38.5 Gy in 10 fx)
96 The Nodes
97 Patients Clinical T1-2 N0 1 or 2 positive SN No gross ECE Treatment: ACOSOG Z-11 Lumpectomy with whole breast irradiation Dose/precise fields not specified Adjuvant systemic therapy by choice (97%) Guiliano A et al JAMA : 569
98 ACOSOG Z-11: Patients calnd SNB Alone # Patients Age, median 56 yrs 54 yrs T size, median 1.7 cm 1.6 cm ER/PR+ 82% 82% Grade 3 29% 28% Guiliano A et al JAMA : 569
99 Outcomes of Z11 (Median f/u: 6.3 years) Recurrence Type ALND (420) SLNB only (436) Locoregional (%) Local Axillary DFS (%) OS (%) All comparisons non-significant Giuliano A et al, Ann Surg (3): Giuliano A et al, JAMA (6):569-75
100 Findings on calnd in Z-11 46% of positive sentinel nodes were micromets Only 106 (27.4%) of patients treated with calnd had additional positive nodes beyond the SN This is a highly select group Guiliano A et al JAMA : 569
101 Radiation Fields in ACOSOG Z % did not receive RT 228 patients (28.5%) had evaluable RT records: 50% received high tangents 19% had a separate nodal field No difference between arms High vs Standard Tangent Fields Axillary Vein Standard Superior Border Axillary LN Lumpectomy Cavity Jagsi R, J Clin Oncol 32(32), 2014
102 IBCSG 23-01: ALND vs SN Only for Micrometastases ct1-t2, micromets in 1-2 SNs (H+E or IHC) Accrued: 934 (target 1950) between Median F/U of 5 years Galimberti et al Lancet Oncol 2013;14:297
103 IBCSG 23-01: Characteristics ALND (n=464) SLNB (n=467) Median Age 53 yrs (23-81) 54 yrs (26-81) T <3 cm 91% 93% ER + 88% 91% Systemic Rx 95% 97% Mastectomy 9% 9% Median # SN 2 (1-9) 1 (1-8) Additional positive nodes 59 (13%) 12 (3%) RT after BCS: 70% External Beam 19% Intraop 9% combination 98% 97%
104 Recurrence IBCSG 23-01: Results ALND (n=464) SLNB (n=467) Local 10 (2%) 8 (2%) Regional 1 (<1%) 5 (1%) Distant 34 (7%) 25 (5%) 5Y DFS 85%* 88%* 5Y OS 96% 96% Galimberti et al Lancet Oncol 2013;14:297 *Log rank p=0.16 non-inferiority p=0.004
105 AMAROS: Study Design CT1-2, N SN negative 1425 SN positive calnd (n=744) axrt (n=681) Rutgers, E. Lancet Oncology 2014; 15:303-10
106 Axillary RT in AMAROS Started <12 wks after SNB 25 x 2Gy or equivalent Level I, II, III and medial SCV Additional AxRT: >4 positive nodes (in dissection arm) Figure adapted from Harris, J Rutgers, E. Lancet Oncology 2014; 15:303-10
107 5-yr Axillary recurrence AMAROS Results (Median f/u 6.1 years) calnd n= % (n=4) AxRT n= % (n=7) 5Y DFS 87% 83% 5Y OS 94% 94% 5 yr Clinical Lymphedema 23% 11% P< Rutgers, E. Lancet Oncology 2014; 15:303-10
108 Disease-Free and Overall Survival Rutgers, E. Lancet Oncology 2014; 15:303-10
109 Substituting RT for Surgery All of these trial indicate RT can substitute for calnd At least in fairly select patients But what volume to irradiate? Tangents alone? High tangents? Supraclav? IMN?
110 MA.20 Randomization Node positive, or high risk nodenegative, s/p breast conservation Whole breast radiation VS Whole breast and regional nodal radiation Whelan TJ et al, NEJM 2015; 373:
111 Node positive Eligibility High risk node negative >5 cm or >2 cm and <10 nodes removed And grade 3 or LVI positive or ER negative Chemotherapy and/or endocrine therapy required Whelan TJ et al, NEJM 2015; 373:
112 MA.20 RT Details Whole breast: 50 Gy/25 fx Cone down: Gy (e - or brachy) IMNs treated with either partially wide tangents or anterior field (electron and photon combination) 50 Gy/25 fx SCV/axilla (AP or AP/PA) Full axilla for >3 positive nodes or <10 dissected 45 Gy (for AP/PA), 50 Gy (AP) Whelan TJ et al, NEJM 2015; 373:
113 Baseline Characteristics WBI N=916 WBI + RNI N=916 Age (mean) Axillary nodes removed (mean) Node ve 89 (10) 89(10) Node +ve (1-3) 780 (85) 776 (85) Tumor size > 2 cm 416 (45) 457 (50) Grade III 387 (42) 390(43) ER ve 235 (26) 232 (25) Adj chemotherapy 829 (91) 830 (91) Adj endocrine therapy 705 (77) 700 (76) Boost irradiation 221 (24) 206 (22) in 39% Whelan TJ et al, NEJM 2015; 373:
114 Baseline Characteristics WBI N=916 WBI + RNI N=916 Age (mean) Axillary nodes removed (mean) Node ve 89 (10) 89(10) Node +ve (1-3) 780 (85) 776 (85) Tumor size > 2 cm 416 (45) 457 (50) Grade III 387 (42) 390(43) ER ve 235 (26) 232 (25) Adj chemotherapy 829 (91) 830 (91) Adj endocrine therapy 705 (77) 700 (76) Boost irradiation 221 (24) 206 (22) in 39% Whelan TJ et al, NEJM 2015; 373:
115 Baseline Characteristics WBI N=916 WBI + RNI N=916 Age (mean) Axillary nodes removed (mean) Node ve 89 (10) 89(10) Node +ve (1-3) 780 (85) 776 (85) Tumor size > 2 cm 416 (45) 457 (50) Grade III 387 (42) 390(43) ER ve 235 (26) 232 (25) Adj chemotherapy 829 (91) 830 (91) Adj endocrine therapy 705 (77) 700 (76) Boost irradiation 221 (24) 206 (22) in 39% Whelan TJ et al, NEJM 2015; 373:
116 10-Year Kaplan Meier Estimates of Survival. Median follow-up 9.5 years Whelan TJ et al. N Engl J Med 2015;373:
117 Ten-year Results (n=1832) 10-Yr No Nodal RT Nodal RT HR p- value LRR* 6.8% 4.3% DFS 77.0% 82.0% OS 81.8% 82.8% *isolated Whelan TJ et al, NEJM 2015; 373:
118 MA-20: Hazard Ratios for Overall Survival Whelan et al, NEJM, 2015; 373:
119 LRR +/- RT by Subtype Approximation Danish 82 b and c ER+ HER2+ Triple Neg ER+ HER2- ER- HER2+ Kyndi et al. JCO 2008; 26:
120 Adverse Events Any lymphedema increased from 4.5% to 8.4%; p = Radiation pneumonitis increased from.2% to 1.2%; p = 0.01 All grade 2 Major cardiac event 0.4 vs 0.9, p= 0.26 *NCI Common toxicity criteria v Whelan TJ et al, NEJM 2015; 373:
121 EORTC Phase III Trial 22922/10925 n= 4,004 Stage I-III, pn+ or pn- w/ central/medial ARM 1: No nodal RT ARM 2: IM and supraclav RT Poortmans PM et al. N Engl J Med 2015;373:
122 Poortmans PM et al. N Engl J Med 2015;373:
123 Poortmans PM et al. N Engl J Med 2015;373:
124 Distant Disease-free and Overall Survival P=0.02 Median follow-up: 10.9 years P=0.06 Poortmans PM et al. N Engl J Med 2015;373:
125 Hazard Ratio for Death, According to Subgroups Poortmans PM et al. N Engl J Med 2015;373:
126 Multicenter French Randomized Trial Randomization: CW, SCV +/- IM N=1407 Eligibility: Mastectomy, larger than 1.0 cm Any node positive Medial/central with or without positive nodes Technique: First 5 interspaces Powered for 10% difference in OS Hennequin et al IJROBP 86(5), 2013
127 Key Patient Characteristics No IM RT (%) IM RT (%) Location: Lateral 236 (36) 232 (35) Medial 426 (64) 440 (65) Nodal status: N0 162 (24) 169 (25) N+ 500 (76) 503 (75) Grade: I/II 349 (53) 360 (54) III 154 (23) 164 (24) Adj chemotherapy 402 (61) 410 (61) Adj hormonal therapy 348 (53) 350 (52) Hennequin et al IJROBP 86(5), 2013
128 Outcome Hennequin: 10 Year Results No IM RT (%) IM RT (%) OS DFS p LR as first event Cardiac Events NS NS Hennequin et al IJROBP 86(5), 2013
129 The Danish Experience Prospective cohort study, Node positive (macroscopic), younger than age 70 All received periclavicular and chest or breast RT LT-sided: RT without IMN (n=1586) RT-sided: RT with IMN (n=1486) Thorsen LBJ et al, J Clin Oncol, epub 2015
130 Median age 56 Key Pt/Tx Characteristics (median follow-up 8.9 years) Mastectomy 65%; BCT 35% ER Positive 80% Positive axillary nodes: % % >10 15% High grade 28% Thorsen LBJ et al, J Clin Oncol, epub 2015
131 75.9% 72.2% Overall Survival, HR 0.82; p=0.005 Breast Cancer Mortality, HR 0.85; p=0.03 Distant Recurrence, HR 0.89; p=0.07 Thorsen LBJ et al, J Clin Oncol, epub 2015
132 More Questions (few answers) What is the relative benefit of IM vs SCV RT Does it make sense to treat SCV alone in patients with difficult anatomy Which subgroups are most likely to benefit ER negative? HER2+ One positive node? What is the long-term risk of increased lung V20 and low-dose cardiac RT?
133 Post-Mastectomy Radiation
134 Meta-analysis of PMRT Trials 22 trials with 8135 women treated with mastectomy + axillary surgery +/- PMRT Adjuvant systemic therapy was used in the majority of patients RT to chest wall, SCV +/- axilla, internal mammary nodes Lancet 2014;383(9935):
135 Absolute Benefits of PMRT (n=8135) % 11.5% 7.9% > % 8.8% 9.3% Lancet 2014;383(9935):
136 Impact of Number of Involved Nodes Lancet 2014;383(9935):
137 McBride et al, MDACC Retrospective review; n =1027 T1, T2; 1-3 nodes Early era: before taxanes, AI Late era: McBride et al, IJROBP Volume 89, Issue 2, 2014,
138 9.5% at 5 years N= % at 5 years McBride et al, IJROBP Volume 89, Issue 2, 2014,
139 2.8% at 5 years N= % at 5-years McBride et al, IJROBP Volume 89, Issue 2, 2014,
140 Effective Systemic Therapy Improves LRR Chemotherapy improves LRR beyond adjuvant RT alone EBCTCG Clarke et al. Lancet 2005; 365:1687 NSABP Anderson SJ et al. JCO 2005; 27 Incremental improvements in systemic therapy further lower LRR Addition of taxanes Addition of trastuzumab
141 TAMOXIFEN CHEMOTHERAPY EBCTCG Overview. Lancet 2005;365:1687
142 10-Year LR in NSABP trials for node-negative tumors Trial ER 10-Year Status LR (%) B-13 No Chemo B-13 Chemo B-14 No Tamoxifen B-14 Tamoxifen Anderson SJ et al. J Clin Oncol 2005:27;2466
143 Impact of Taxanes on LRR
144 Impact of H on LRR: First Events Patients B-31 N9831 (NCCTG) Control Trastuzumab Control Trastuzumab All patients Alive and event-free Any First event Local or Reg Recurrence Distant Recurrence CBC Second Primary Death Without Disease Romond et al NEJM 353:16, 2005
145 Can Systemic Therapy Select Patients who Don t Benefit from RT? NSABP Experience Preop AC arm from B-18 and the preop AC +/- T arms from B-27 N= 1,071 mastectomy patients SNB performed after chemotherapy pcr was defined as no residual invasive disease (DCIS permitted) Mamounas E et al JCO : 3960
146 Predictors of LRR after Mastectomy: MVA Clinical tumor size at presentation Clinical node status at presentation Path node status after chemotherapy Path response in the breast Both the initial clinical and the final path stage must be used to determine LR risk Mamounas E et al JCO : 3960
147 Mamounas et al: MVA Variable HR 95% CI P ct: > 5 vs < 5 cm cn+ vs cn pcr nodes vs Complete pcr <.001 Node positive vs Complete pcr <.001 Mamounas E et al JCO : 3960
148 Mamounas et al: MVA Variable HR 95% CI p ct: > 5 vs < 5 cm cn+ vs cn pcr nodes vs Complete pcr <.001 Node positive vs Complete pcr <.001 Mamounas E et al JCO : 3960
149 10-Year Risk of LRR Mastectomy, Clinical T 5 cm Mastectomy Clinical T > 5 cm Mamounas E et al JCO : 3960
150 NEOADJUVANT THERAPY 1 SURGERY 2 NSABP B-51/RTOG 1304 Clinical T1 3, N1 Positive Axillary Nodes by FNA or Core Accrual goal 1636 patients over 5 years R A N D O M I Z A T I O N Mastectomy Breast Conservation PMRT No PMRT Breast alone Breast and Regional Nodes 1 Minimum 12 weeks, trastuzumab when appropriate 2 Path Documentation of Negative Axillary Nodes (by ALND or by SLNBx ± ALND)
151 DCIS
152 Randomized Trials of Excision +/- RT N FU E alone E + RT NSABP B y 35% 20% invasive: 20% 11% DCIS: 15% 9% EORTC y 30% 17% invasive: 50% 56% DCIS: 50% 44% UK y 19% 7% invasive: 7% 4% DCIS: 12% 3% Swedish y 27% 12% invasive: 12% 7% DCIS: 15% 5%
153 EBCTCG Meta-Analysis: DCIS N=3729 Correa, JNCI Monogr 41: , 2010
154 RTOG 9804: Details Randomized, RT vs No RT; Low or intermediate grade Smaller than 2.5 cm; margins >3mm N = 636 (1790 planned accrual) Tam optional (62%) Median follow-up 7.1 years McCormick et al. JCO 2015;33:
155 RTOG 9804: Results McCormick B, JCO 33(7), 2015
156 DCIS: Omission of RT ECOG 5194 Study design Single arm, excision without radiation Tam optional (30%) At least 3 mm margin or negative re-excision Low risk: Low or intermediate grade Smaller than 2.5 cm High risk: High grade, smaller than 1.0 cm Solin LJ, JCO epub ahead of print, 2015
157 ECOG 5194, Low Risk Any Ipsi Breast Event (%) Invasive Ipsi Breast Event (%) 5 years 6 ( ) 2.7 ( ) 7 years 9.5 ( ) 4.8 ( ) 10 years 12.5 ( ) 6.4 ( ) 12 years 14.4 (CI ) 7.5 ( ) N=561 Median follow-up 12.3 years Solin LJ, JCO epub ahead of print, 2015
158 ECOG 5194, High Risk (High grade, Smaller than 1.0 cm) Any Ipsi Breast Event (%) Invasive Ipsi Breast Event (%) 5 years 15 ( ) 5.3 ( ) 7 years 18.2 ( ) 7.6 ( ) 10 years 24.6 ( ) 13.4 ( ) 12 years 24.6 ( ) 13.4 ( ) N=104 Solin LJ, JCO epub ahead of print, 2015
159 Oncotype DX DCIS Score 12/21 genes from the Oncotype DX Recurrence Score Continues score (0-100) 3 specified risk groups Low (<39) Int (39-54) High (>54) 7 cancer-related genes 5 reference genes Solin LJ, JNCI 2013, 105
160 Oncotype DCIS Score: ECOG 5194 <2.5 cm, grade I or II <1.0 cm, grade III Margins > 3mm Solin LJ, et al JNCI 2013, 105
161 Ontario DCIS Validation N= Rakovitch et al Br Res Treat, 2015, 152
162 Conclusions Breast conservation is an appropriate option for most women with early-stage disease with outstanding long-term local control We are beginning to understand tumor biology as it relates to local control, and hopefully this will allow omission of RT in select patients Hypofractionation is the best option for most women with early-stage disease undergoing BCT Beginning to see the maturation of the APBI trials. Over the next 5 years I think we'll have a much better idea of long term toxicity and efficacy
163 Conclusions Breast conservation is an appropriate option for most women with early-stage disease with outstanding long-term local control We are beginning to understand tumor biology as it relates to local control, and hopefully this will allow omission of RT in select patients Hypofractionation is the best option for most women with early-stage disease undergoing BCT Beginning to see the maturation of the APBI trials. Over the next 5 years I think we'll have a much better idea of long term toxicity and efficacy
164 Conclusions Breast conservation is an appropriate option for most women with early-stage disease with outstanding long-term local control We are beginning to understand tumor biology as it relates to local control, and hopefully this will allow omission of RT in select patients Hypofractionation is the best option for most women with early-stage disease undergoing BCT Beginning to see the maturation of the APBI trials. Over the next 5 years I think we'll have a much better idea of long term toxicity and efficacy
165 Conclusions Breast conservation is an appropriate option for most women with early-stage disease with outstanding long-term local control We are beginning to understand tumor biology as it relates to local control, and hopefully this will allow omission of RT in select patients Hypofractionation is the best option for most women with early-stage disease undergoing BCT Beginning to see the maturation of the APBI trials. Over the next 5 years I think we'll have a much better idea of long term toxicity and efficacy
166 Conclusions (continued) Axillary dissection is not warranted for many (?most) patients with 1-2 positive sentinel nodes Appropriate nodal fields still in evolution, but my bar to treat the nodes has dropped Whom to treat with PMRT is still unclear, particularly with modern systemic therapy, but overall LRR is lower than previously appreciated Clinically node positive patients who achieve pcr may not need RT (please enroll on B-51) DCIS: Hope for improved molecular characterization of disease, and ability to predict LR
167 Conclusions (continued) Axillary dissection is not warranted for many (?most) patients with 1-2 positive sentinel nodes Appropriate nodal fields still in evolution, but my bar to treat the nodes has dropped Whom to treat with PMRT is still unclear, particularly with modern systemic therapy, but overall LRR is lower than previously appreciated Clinically node positive patients who achieve pcr may not need RT (please enroll on B-51) DCIS: Hope for improved molecular characterization of disease, and ability to predict LR
168 Conclusions (continued) Axillary dissection is not warranted for many (?most) patients with 1-2 positive sentinel nodes Appropriate nodal fields still in evolution, but my bar to treat the nodes has dropped Whom to treat with PMRT is still unclear, particularly with modern systemic therapy, but overall LRR seems to be lower than previously appreciated Clinically node positive patients who achieve pcr may not need RT (please enroll on B-51) DCIS: Hope for improved molecular characterization of disease, and ability to predict LR
169 Conclusions (continued) Axillary dissection is not warranted for many (?most) patients with 1-2 positive sentinel nodes Appropriate nodal fields still in evolution, but my bar to treat the nodes has dropped Whom to treat with PMRT is still unclear, particularly with modern systemic therapy, but overall LRR is lower than previously appreciated Clinically node positive patients who achieve pcr may not need RT (please enroll on B-51) DCIS: Hope for improved molecular characterization of disease, and ability to predict LR
170 Conclusions (continued) Axillary dissection is not warranted for many (?most) patients with 1-2 positive sentinel nodes Appropriate nodal fields still in evolution, but my bar to treat the nodes has dropped Whom to treat with PMRT is still unclear, particularly with modern systemic therapy, but overall LRR is lower than previously appreciated Clinically node positive patients who achieve pcr may not need RT (please enroll on B-51) DCIS: Hope for improved molecular characterization of disease, and ability to predict LR
Principles of breast radiation therapy
ANZ 1601/BIG 16-02 EXPERT ESMO Preceptorship Program 2017 Principles of breast radiation therapy Boon H Chua Professor Director of Cancer and Haematology Services UNSW Sydney and Prince of Wales Hospital
More informationHow can we Personalize RT as part of Breast-Conserving Therapy?
How can we Personalize RT as part of Breast-Conserving Therapy? Jay R. Harris Dana-Farber Cancer Institute (DFCI) Brigham and Women s Hospital (BWH) Harvard Medical School Disclosures I have no COI disclosures
More information2017 Topics. Biology of Breast Cancer. Omission of RT in older women with low-risk features
2017 Topics Biology of Breast Cancer Early-stage HER2+ breast cancer-can we avoid RT? Prediction tools for locoregional recurrence Omission of RT in older women with low-risk features Local-Regional Recurrence
More informationImplications of ACOSOG Z11 for Clinical Practice: Surgical Perspective
:$;7)#*8'-87*4BCD'E7)F'31$4.$&'G$H'E7)F&'GE'>??ID >?,"'@4,$)4*,#74*8'!74/)$++'74',"$'A.,.)$'7%'()$*+,'!*42$)!7)74*67&'!3 6 August 2011 Implications of ACOSOG Z11 for Clinical
More informationRadiotherapy Management of Breast Cancer Treated with Neoadjuvant Chemotherapy. Julia White MD Professor, Radiation Oncology
Radiotherapy Management of Breast Cancer Treated with Neoadjuvant Chemotherapy Julia White MD Professor, Radiation Oncology Agenda Efficacy of radiotherapy in the management of breast cancer in the Adjuvant
More informationRadiation and DCIS. The 16 th Annual Conference on A Multidisciplinary Approach to Comprehensive Breast Care and Imaging
Radiation and DCIS The 16 th Annual Conference on A Multidisciplinary Approach to Comprehensive Breast Care and Imaging Einsley-Marie Janowski, MD, PhD Assistant Professor Department of Radiation Oncology
More informationRadiotherapy Implications of ACOSOG Z-11 for Clinical Practice. Julia White, MD Professor of Radiation Oncology Medical College of Wisconsin
1 Radiotherapy Implications of ACOSOG Z-11 for Clinical Practice Julia White, MD Professor of Radiation Oncology Medical College of Wisconsin Disclosures: none Agenda 1. ACOSOG Z-11: Another perspective
More informationImplications of ACOSOG Z11 for Clinical Practice: Surgical Perspective
Memorial Sloan-Kettering Cancer Center 1275 York Avenue, New York, NY 10065 10th International Congress on the Future of Breast Cancer Coronado, CA 6 August 2011 Implications of ACOSOG Z11 for Clinical
More informationBREAST CONSERVATION TREATMENT IN EARLY STAGE DISEASE AND DCIS LAWRENCE J. SOLIN, MD, FACR, FASTRO
BREAST CONSERVATION TREATMENT IN EARLY STAGE DISEASE AND DCIS LAWRENCE J. SOLIN, MD, FACR, FASTRO Chairman Department of Radiation Oncology Albert Einstein Healthcare Network Philadelphia, PA Professor
More informationEvolution of Regional Nodal Management of Breast Cancer
Evolution of Regional Nodal Management of Breast Cancer Bruce G. Haffty, MD Director (Interim) Rutgers Cancer Institute of New Jersey Professor and Chair Department of Radiation Oncology Rutgers, The State
More informationWhy Do Axillary Dissection? Nodal Treatment and Survival NSABP B04. Revisiting Axillary Dissection for SN Positive Patients
Memorial Sloan-Kettering Cancer Center 1275 York Avenue, New York, NY 10065 10th International Congress on the Future of Breast Cancer Coronado, CA Why Do Axillary Dissection? 6 August 2011 Implications
More informationPost-Mastectomy RT after Neoadjuvant Chemotherapy (NAC)
Post-Mastectomy RT after Neoadjuvant Chemotherapy (NAC) Jay R. Harris, M.D. Dana-Farber Cancer Institute Brigham and Women s Hospital Harvard Medical School Conclusions When considering PMRT, use both
More informationCase Conference: Post-Mastectomy Radiotherapy
Case Conference: Post-Mastectomy Radiotherapy Outline - Case Intro Guidelines Studies - Case Conclusion Summary Outline Case Intro to PMRT Guidelines Studies Case conclusion Summary Outline - Case Intro
More informationWhole Breast Irradiation: Class vs. Hypofractionation
Whole Breast Irradiation: Class vs. Hypofractionation Kyung Hwan Shin, MD, PhD. Dept. of Radiation Oncology, Seoul National University Hospital 2018. 4. 6. GBCC Treatment Trends of Early Breast Cancer
More informationBREAST CONSERVATION TREATMENT IN EARLY STAGE DISEASE AND DCIS LAWRENCE J. SOLIN, MD, FACR, FASTRO
BREAST CONSERVATION TREATMENT IN EARLY STAGE DISEASE AND DCIS LAWRENCE J. SOLIN, MD, FACR, FASTRO Chairman Department of Radiation Oncology Albert Einstein Medical Center Philadelphia, PA Professor (Adjunct)
More informationState of the Art in 2000 State of the Art today Gazing forward
2010 Buschke Lecture: The Relationship between Local Recurrence and Survival in Breast Cancer Jay R. Harris Dana-Farber Cancer Institute (DFCI) Brigham and Women s Hospital (BWH) Harvard Medical School
More informationPMRT for N1 breast cancer :CONS. Won Park, M.D., Ph.D Department of Radiation Oncology Samsung Medical Center
PMRT for N1 breast cancer :CONS Won Park, M.D., Ph.D Department of Radiation Oncology Samsung Medical Center DBCG 82 b & c Overgaard et al Radiot Oncol 2007 1152 pln(+), 8 or more nodes removed Systemic
More informationWhat are Adequate Margins of Resection for Breast-Conserving Therapy?
What are Adequate Margins of Resection for Breast-Conserving Therapy? Jay R. Harris Dana-Farber Cancer Institute (DFCI) Brigham and Women s Hospital (BWH) Harvard Medical School What are Adequate Margins
More informationEvaluating the Z011 study and how local-regional therapy for early breast cancer may change
Evaluating the Z011 study and how local-regional therapy for early breast cancer may change Karen Hoffman, M.D., M.H.Sc., M.P.H. Dept of Radiation Oncology The University of Texas MD Anderson Cancer Center
More informationPartial Breast Irradiation for Breast Conserving Therapy
To Radiate or Not? Is APBI the Right Compromise Solution? Partial Breast Irradiation for Breast Conserving Therapy Julia White MD Professor, Radiation Oncology Agenda Role of radiotherapy in breast conservation
More informationIntraoperative. Radiotherapy
Intraoperative Radiotherapy ROBERTO ORECCHIA UNIVERSITY of MILAN & EUROPEAN INSTITUTE of ONCOLOGY & CNAO FOUNDATION Breast Cancer Brescia, 30th September 2011 IORT, very selective technique to intensify
More informationCurrent Status of Accelerated Partial Breast Irradiation. Julia White MD Professor, Radiation Oncology
Current Status of Accelerated Partial Breast Irradiation Julia White MD Professor, Radiation Oncology I have no disclosures relative to the presented material Agenda ABPI Timeline APBI by Method Clinical
More informationResults of the ACOSOG Z0011 Trial
DCIS and Early Breast Cancer Symposium JUNE 15-17 2012 CAPPADOCIA Results of the ACOSOG Z0011 Trial Kelly K. Hunt, M.D. Professor of Surgery Axillary Node Dissection Staging, Regional control, Survival
More information03/14/2019. Postmastectomy radiotherapy; the meta-analyses, and the paradigm change to altered fractionation Mark Trombetta M.D.
radiotherapy; the meta-analyses, and the paradigm change to altered fractionation Mark Trombetta M.D. Division of Radiation Oncology Allegheny Health Network Cancer Institute Professor of Radiation Oncology
More informationNeoadjuvant Treatment of. of Radiotherapy
Neoadjuvant Treatment of Breast Cancer: Role of Radiotherapy Neoadjuvant Chemotherapy Many new questions for radiation oncology? lack of path stage to guide indications should treatment response affect
More informationHypofractionated Radiotherapy for breast cancer: Updated evidence
2 rd Bangladesh Breast Cancer Conference, Dhaka, December 2017 Hypofractionated Radiotherapy for breast cancer: Updated evidence Tabassum Wadasadawala Associate Professor of Radiation Oncology Tata Memorial
More informationObjectives Intraoperative Radiation Therapy for Early Stage Breast Cancer
Objectives Intraoperative Radiation Therapy for Early Stage Breast Cancer Cristina Lopez-Peñalver, MD, FACS October 11, 2014 Disclosures I have no relevant commercial relationships to disclose. Discuss
More informationDebate Axillary dissection - con. Prof. Dr. Rodica Anghel Institute of Oncology Bucharest
Debate Axillary dissection - con Prof. Dr. Rodica Anghel Institute of Oncology Bucharest Summer School of Oncology, third edition Updated Oncology 2015: State of the Art News & Challenging Topics Bucharest,
More informationIORT What We ve Learned So Far
IORT What We ve Learned So Far The 16 th Annual Conference on A Multidisciplinary Approach to Comprehensive Breast Care and Imaging Einsley-Marie Janowski, MD, PhD Assistant Professor Department of Radiation
More informationThe Role of Sentinel Lymph Node Biopsy and Axillary Dissection
The Role of Sentinel Lymph Node Biopsy and Axillary Dissection Henry Mark Kuerer, MD, PhD, FACS Department of Surgical Oncology University of Texas MD Anderson Cancer Center SLN Biopsy Revolutionized surgical
More informationACCELERATED BREAST IRRADIATION EVOLVING PARADIGM FOR TREATMENT OF EARLY STAGE BREAST CANCER
ACCELERATED BREAST IRRADIATION EVOLVING PARADIGM FOR TREATMENT OF EARLY STAGE BREAST CANCER KHANH NGUYEN, MD, MA DEPARTMENT OF RADIATION ONCOLOGY BAYHEALTH CANCER CENTER BREAST CANCER STATISTICS Most common
More informationRecent Updates in Surgical Management of Breast Cancer Asian Patient's Perspective
Recent Updates in Surgical Management of Breast Cancer Asian Patient's Perspective Tokyo-West Tokushukai Hospital Department of Breast Oncology Tokyo-West Tokushukai Hospital, Tokyo, Japan Kaz Sato, MD,
More informationBreast cancer. (early and advanced) Radiotherapy
Breast cancer (early and advanced) Radiotherapy Need for RT. ESTRO-HERO estimation Tumor site RT courses 2012 Increase in number 2025 Increase in rate (%) Breast 396,891 40,524 10.2 Lung 315,197 56,558
More informationSurgical Considerations in Breast Cancer treated with Neoadjuvant Therapy
Surgical Considerations in Breast Cancer treated with Neoadjuvant Therapy Rebecca Warburton MD Department of Surgery, University of British Columbia Mount Saint Joseph Hospital, Providence Health Care
More informationSan Antonio Breast Cancer Symposium 2010 Highlights Radiotherapy
San Antonio Breast Cancer Symposium 2010 Highlights Radiotherapy Kathleen C. Horst, M.D. Assistant Professor Department of Radiation Oncology Stanford University The Optimal SEquencing of Adjuvant Chemotherapy
More informationThe Management of Breast Cancer 2015 ASTRO Spring Refresher
The Management of Breast Cancer 2015 ASTRO Spring Refresher Gary M. Freedman, M.D. Associate Professor Disclosure I have no conflicts of interest to disclose. 2 Learning Objectives Apply knowledge of randomized
More informationAccelerated Radiation Treatment for Early Stage Breast Cancer. update and perspective
Accelerated Radiation Treatment for Early Stage Breast Cancer update and perspective School of Breast Oncology Atlanta, 11/2013 Douglas W. Arthur, M.D. Professor Traditional Whole Breast Irradiation WBI
More informationConsensus Guideline on Accelerated Partial Breast Irradiation
Consensus Guideline on Accelerated Partial Breast Irradiation Purpose: To outline the use of accelerated partial breast irradiation (APBI) for the treatment of breast cancer. Associated ASBS Guidelines
More informationSSO-ASTRO Consensus Guidance Margins for Breast-Conserving Surgery with Whole Breast Irradiation in Stage I and II Invasive Breast Cancer
SSO-ASTRO Consensus Guidance Margins for Breast-Conserving Surgery with Whole Breast Irradiation in Stage I and II Invasive Breast Cancer Dr. Yvonne Tsang St. Paul s Hospital Introductions Breast-conserving
More informationInvasive Breast Cancer
Invasive Breast Cancer Eileen Rakovitch MD MSc FRCPC Sunnybrook Health Sciences Centre Medical Director, Louise Temerty Breast Cancer Centre LC Campbell Chair in Breast Cancer Research Associate Professor,
More informationBreast cancer: Clinical evidence. of new treatments. Aero academy Conference Innovation and Safety. Patients Come First
Breast cancer: Clinical evidence of new treatments Aero academy Conference Innovation and Safety Patients Come First January 26 & 27, 2018 Lisbon, Portugal Disclosure & Disclaimer An honorarium is provided
More informationPage 1. AHN-JHU Breast Cancer Symposium. Novel Local Regional Clinical Trials. Background. Neoadjuvant Chemotherapy Benefit.
AHN-JHU Breast Cancer Symposium Novel Local Regional Clinical Trials March 22, 2019 Thomas B. Julian, MD, FACS Associate Medical Director, Cancer Program Development, ANH Cancer Institute Background In
More informationAdvances in Breast Cancer
Advances in Breast Cancer Developed in collaboration Learning Objectives Upon completion, participants should be able to: Apply genomic medicine to treatment decisions for patients with HR+/HER2- early
More informationPost-Lumpectomy Radiation Techniques and Toxicities
Post-Lumpectomy Radiation Techniques and Toxicities Laura Willson, MD Abbott Northwestern Hospital Dept. of Radiation Oncology February 2, 2019 Learning Objectives How radiation therapy works Standard
More informationNSABP Pivotal Breast Cancer Clinical Trials: Historical Perspective, Recent Results and Future Directions
1 1 NSABP Pivotal Breast Cancer Clinical Trials: Historical Perspective, Recent Results and Future Directions Terry Mamounas, M.D., M.P.H., F.A.C.S. Medical Director, Comprehensive Breast Program UF Health
More informationBreast Cancer: Management of the Axilla in Greg McKinnon MD FRCSC SON Vancouver Oct 2016
Breast Cancer: Management of the Axilla in 2016 Greg McKinnon MD FRCSC SON Vancouver Oct 2016 No Disclosures Principle #1 There is no point talking about surgical therapy in isolation. From a patient
More informationWhat is an Adequate Lumpectomy Margin in 2018?
What is an Adequate Lumpectomy Margin in 2018? Stuart J. Schnitt, M.D. Brigham and Women s Hospital, Dana-Farber Cancer Institute, and Harvard Medical School Boston, MA None Disclosures Topics Current
More informationRecent Update in Surgery for the Management of Breast Cancer
Recent Update in Surgery for the Management of Breast Cancer Wonshik Han, MD, PhD Professor, Department of Surgery, Seoul National University College of Medicine Chief of Breast Care Center, Seoul National
More informationEarly Stage Breast Cancer
Local-Regional Management of Early Stage Breast Cancer Meena S. Moran, MD Associate Professor, Yale University School of Medicine Disclosure I have no conflicts of interest to disclose. Learning Objectives
More informationRADIOTHERAPY IN BREAST CANCER :
RADIOTHERAPY IN BREAST CANCER : PAST, PRESENT, FUTURE Dr Jyotirup Goswami Consultant Radiation Oncologist Narayana Cancer Institute Narayana Superspecialty Hospital Breast cancer is the classic paradigm
More informationBreast Cancer Radiotherapy: Clinical challenges in 2011 from a European Perspective. Dr DA WHEATLEY CONSULTANT ONCOLOGIST ROYAL CORNWALL HOSPITAL
Breast Cancer Radiotherapy: Clinical challenges in 2011 from a European Perspective Dr DA WHEATLEY CONSULTANT ONCOLOGIST ROYAL CORNWALL HOSPITAL Radiotherapy in Early Breast Cancer Why do we do it? Who
More informationSurgical Issues in Neoadjuvant Chemotherapy
14 th Bossche Mamma Congress Ruwenbergstraat 7 5271 AG Sint Michielsgestel June 14, 2016 Surgical Issues in Neoadjuvant Chemotherapy Tari A. King MD FACS Chief, Breast Surgery Dana Farber/Brigham and Women
More informationAccelerated Radiation Treatment for Early Stage Breast Cancer. update and perspective
Accelerated Radiation Treatment for Early Stage Breast Cancer update and perspective School of Breast Oncology Atlanta, 11/2012 Douglas W. Arthur, M.D. Professor Traditional Whole Breast Irradiation WBI
More informationALND. Dr. MJ Vrancken
ALND Dr. MJ Vrancken ALND in primary surgery se1ng Axillary lymph node dissec8on (ALND) Very nice opera8on; dorsal approach 2 ALND in primary surgery se1ng Axillary lymph node dissec8on (ALND) Very nice
More informationBreast Conservation Therapy
May 18, 2018 Breast Conservation Therapy One Treatment No Longer Fits All Presenter: Paul B. Fowler, MD Radiation Oncology, MGSH/MUMH 1 Objectives: 1. Define stages of breast cancer that are candidates
More information16/09/2015. ACOSOG Z011 changing practice. Presentation outline. Nodal mets #1 prognostic tool. Less surgery no change in oncologic outcomes
ACOSOG Z011 changing practice The end of axillary US/FNA? Preoperative staging of the axilla in the era of Z011 Adena S Scheer MD MSc FRCSC Surgical Oncologist, St. Michael s Hospital Assistant Professor,
More informationIs Complete Axillary Dissection Needed Following Mastectomy and Sentinel Node Biopsy for N1 disease?
Is Complete Axillary Dissection Needed Following Mastectomy and Sentinel Node Biopsy for N1 disease? Mylin A. Torres, MD Director, Glenn Family Breast Center Louis and Rand Glenn Family Chair in Breast
More informationBreast Surgery When Less is More and More is Less. E MacIntosh, MD June 6, 2015
Breast Surgery When Less is More and More is Less E MacIntosh, MD June 6, 2015 Presenter Disclosure Faculty: E. MacIntosh Relationships with commercial interests: None Mitigating Potential Bias Not applicable
More information2017 San Antonio Breast Cancer Symposium: Local Therapy Highlights
2017 San Antonio Breast Cancer Symposium: Local Therapy Highlights Mylin A. Torres, M.D. Director, Glenn Family Breast Center Associate Professor Department of Radiation Oncology Winship Cancer Institute
More informationRadiation Therapy for the Oncologist in Breast Cancer
REVIEW ARTICLE Chonnam National University Medical School Sung-Ja Ahn, M.D. Adjuvant Tamoxifen with or without in Patients 70 Years of Age with Stage I ER-Positive Breast Cancer: Efficacy Outcomes (10
More informationSurgical Advances in the Treatment of Breast Cancer. Laura Kruper, MD, MSCE Chief, Breast Surgery
Surgical Advances in the Treatment of Breast Cancer Laura Kruper, MD, MSCE Chief, Breast Surgery Nothing to disclose DISCLOSURE LESS IS MORE Radiation Lymph nodes Reconstruction Less is More! Radiation
More information8/8/2011. PONDERing the Need to TAILOR Adjuvant Chemotherapy in ER+ Node Positive Breast Cancer. Overview
Overview PONDERing the Need to TAILOR Adjuvant in ER+ Node Positive Breast Cancer Jennifer K. Litton, M.D. Assistant Professor The University of Texas M. D. Anderson Cancer Center Using multigene assay
More informationNew Technologies in Radiation Oncology. Catherine Park, MD, MPH Advocate Good Shepherd Hospital
New Technologies in Radiation Oncology Catherine Park, MD, MPH Advocate Good Shepherd Hospital Breast Radiation Early Stage Breast Cancer Whole Breast Radiation Delivered to the whole breast Boost to the
More informationThe Challenge of Individualizing Loco-Regional Treatments for Patients with Localized Breast Cancer
The Challenge of Individualizing Loco-Regional Treatments for Patients with Localized Breast Cancer Le défi des traitements locorégionaux individualisés pour les patientes présentant un cancer du sein
More informationBruno CUTULI Policlinico Courlancy REIMS. WORKSHOP SULL IRRADIAZIONE MAMMARIA IPOFRAZIONATA Il carcinoma duttale in situ
Bruno CUTULI Policlinico Courlancy REIMS WORKSHOP SULL IRRADIAZIONE MAMMARIA IPOFRAZIONATA Il carcinoma duttale in situ XXI CONGRESSO AIRO GENOVA 22.11.2011 INTRODUCTION Due to wide diffusion of mammography,
More informationCURRENT CONTROVERSIES IN BREAST CANCER SURGERY Less or more!?
CURRENT CONTROVERSIES IN BREAST CANCER SURGERY Less or more!? I have no Disclosures Wolfgang Gatzemeier Breast Unit Milan, Italy 17th ESO-ESMO- EONS Masterclass in Clinical Oncology 24-29 MARCH 2018 Optimal
More informationLoco-Regional Management After Neoadjuvant Chemotherapy
1 Loco-Regional Management After Neoadjuvant Chemotherapy Terry Mamounas, M.D., M.P.H., F.A.C.S. Medical Director, Comprehensive Breast Program UF Health Cancer Center at Orlando Health Professor of Surgery,
More informationGenomic Profiling of Tumors and Loco-Regional Recurrence
1 Genomic Profiling of Tumors and Loco-Regional Recurrence Terry Mamounas, M.D., M.P.H., F.A.C.S. Medical Director, Comprehensive Breast Program UF Health Cancer Center at Orlando Health Professor of Surgery,
More informationARROCase - April 2017
ARROCase - April 2017 Radiation Indications in the setting of Neoadjuvant chemotherapy for Breast Cancer Lauren Colbert, MD, MSCR Faculty Mentor: Benjamin Smith, MD UT MD Anderson Cancer Center 37 year
More informationConsiderations in Adjuvant Chemotherapy. Joyce O Shaughnessy, MD Baylor Sammons Cancer Center Texas Oncology US Oncology
Considerations in Adjuvant Chemotherapy Joyce O Shaughnessy, MD Baylor Sammons Cancer Center Texas Oncology US Oncology 80 70 60 50 40 30 20 10 0 EBCTCG 2005/6 Overview Control Arms with No Systemic Treatment
More informationAccelerated Partial Breast Irradiation
Accelerated Partial Breast Irradiation OSCO/OU Stephenson Cancer Center Saturday, March 5, 2016 Robert Kuske, MD, FAACE Founder, Medical Director Arizona Breast Cancer Specialists Scottsdale, Arizona 1
More informationProphylactic Mastectomy State of the Art
Memorial Sloan-Kettering Cancer Center 1275 York Avenue, New York, NY 10065 6 th Brazilian Breast Cancer Conference Sao Paulo, Brazil 9 March 2012 Prophylactic Mastectomy State of the Art Monica Morrow
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Accelerated Breast Irradiation and Brachytherapy Boost Page 1 of 23 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Accelerated Breast Irradiation and Brachytherapy
More informationPatient Selection for APBI. C. Polgár National Institute ofoncology, Budapest, Hungary
Patient Selection for APBI C. Polgár National Institute ofoncology, Budapest, Hungary Patient-, tumour- and treatment related factors affecting decision making in patient selection for APBI Patient age
More informationSentinel Lymph Node Biopsy for Breast Cancer
Sentinel Lymph Node Biopsy for Breast Cancer Registrar Tutorial Adam Cichowitz Surgical Registrar The Royal Melbourne Hospital Sentinel Lymph Node Biopsy Axillary LN status important prognostic factor
More informationUK Interdisciplinary Breast Cancer Symposium. Should lobular phenotype be considered when deciding treatment? Michael J Kerin
UK Interdisciplinary Breast Cancer Symposium Should lobular phenotype be considered when deciding treatment? Michael J Kerin Professor of Surgery National University of Ireland, Galway and Galway University
More informationClinical Trials of Proton Therapy for Breast Cancer. Andrew L. Chang, MD 張維安 Study Chair
Clinical Trials of Proton Therapy for Breast Cancer Andrew L. Chang, MD 張維安 Study Chair AndrewLChangMD@gmail.com Disclosure Proton Center Development Corporation Scripps San Diego Proton Therapy Center
More informationSpeaker s Bureau. Travel expenses. Advisory Boards. Stock. Genentech Invuity Medtronic Pacira. Faxitron. Dune TransMed7 Genomic Health.
Management of DCIS Shawna C. Willey, MD, FACS Professor of Surgery, Georgetown University Director, Medstar Regional Breast Health Program Chief, Department of Surgery Medstar Georgetown University Hospital
More informationLoco-Regional Management After Neoadjuvant Chemotherapy
1 Loco-Regional Management After Neoadjuvant Chemotherapy Terry Mamounas, M.D., M.P.H., F.A.C.S. Medical Director, Comprehensive Breast Program UF Health Cancer Center at Orlando Health Professor of Surgery,
More informationWhy Choose Brachytherapy and Not External Beam RT or IORT?
May 30 31, 2014 Miami Beach, FL USA Why Choose Brachytherapy and Not External Beam RT or IORT? Csaba Polgár, MD, PhD, MSc National Institute of Oncology Budapest, Hungary 1 Disclosure Csaba Polgár, MD,
More informationExtended Hormonal Therapy
Extended Hormonal Therapy Dr. Caroline Lohrisch, Medical Oncologist, BC Cancer Agency Vancouver Centre November 1, 2014 www.fpon.ca Optimal Endocrine Therapy for Women with Hormone Receptor Positive Early
More informationBalancing Evidence and Clinical Practice in the Treatment of Localized Breast Cancer May 5, 2006
Balancing Evidence and Clinical Practice in the Treatment of Localized Breast Cancer May 5, 2006 Deborah Hamolsky MS, RN : DCIS Carol Franc Buck Breast Care Center UCSF Comprehensive Cancer Center Jane
More informationProtocol of Radiotherapy for Breast Cancer
107 年 12 月修訂 Protocol of Radiotherapy for Breast Cancer Indication of radiotherapy Indications for Post-Mastectomy Radiotherapy (1) Axillary lymph node 4 positive (2) Axillary lymph node 1-3 positive:
More informationBreast Cancer. Dr. Andres Wiernik 2017
Breast Cancer Dr. Andres Wiernik 2017 Agenda: The Facts! (Epidemiology/Risk Factors) Biological Classification/Phenotypes of Breast Cancer Treatment approach Local Systemic Agenda: The Facts! (Epidemiology/Risk
More informationEvolving Insights into Adjuvant Chemotherapy. Joyce O Shaughnessy, MD Baylor Sammons Cancer Center Texas Oncology US Oncology
Evolving Insights into Adjuvant Chemotherapy Joyce O Shaughnessy, MD Baylor Sammons Cancer Center Texas Oncology US Oncology 80 70 60 50 40 30 20 10 0 EBCTCG 2005/6 Overview Control Arms with No Systemic
More informationDisclosure. Objectives 03/19/2019. Current Issues in Management of DCIS Radiation Oncology Considerations
Current Issues in Management of DCIS Radiation Oncology Considerations Fariba Asrari, M.D. Director. Johns Hopkins Breast Center at Green Spring Station Department of Radiation Oncology & Molecular Sciences
More informationEmerging Approaches for (Neo)Adjuvant Therapy for ER+ Breast Cancer
Emerging Approaches for (Neo)Adjuvant Therapy for E+ Breast Cancer Cynthia X. Ma, M.D., Ph.D. Associate Professor of Medicine Washington University in St. Louis Outline Current status of adjuvant endocrine
More informationSurgical Therapy: Sentinel Node Biopsy and Breast Conservation
Surgical Therapy: Sentinel Node Biopsy and Breast Conservation Stephen B. Edge, MD Professor of Surgery and Oncology Roswell Park Cancer Institute University at Buffalo Dr. Roswell Park: Tradition in Cancer
More informationTargeting Surgery for Known Axillary Disease. Abigail Caudle, MD Henry Kuerer, MD PhD Dept. Surgical Oncology MD Anderson Cancer Center
Targeting Surgery for Known Axillary Disease Abigail Caudle, MD Henry Kuerer, MD PhD Dept. Surgical Oncology MD Anderson Cancer Center Nodal Ultrasound at Diagnosis Whole breast and draining lymphatic
More informationThe Role of Pathologic Complete Response (pcr) as a Surrogate Marker for Outcomes in Breast Cancer: Where Are We Now?
1 The Role of Pathologic Complete Response (pcr) as a Surrogate Marker for Outcomes in Breast Cancer: Where Are We Now? Terry Mamounas, M.D., M.P.H., F.A.C.S. Medical Director, Comprehensive Breast Program
More informationBy Rufus Mark, MD, Gail Lebovic, MD, Valerie Gorman, MD, Oscar Calvo, PhD. TABLE 1 EARLY STAGE BREAST CANCER RANDOMIZED TRIALS M vs.
EVOLUTION OF BREAST CONSERVATION RADIATION TREATMENT TECHNIQUES IN BREAST CANCER : FROM 6 WEEKS TO 3 WEEKS TO 1 WEEK TO 1 DAY AND FROM WHOLE BREAST TO PARTIAL BREAST By Rufus Mark, MD, Gail Lebovic, MD,
More informationESMO Breast Cancer Preceptorship Singapore November Special Issues in Treatment of Young Women with Breast Cancer
ESMO Breast Cancer Preceptorship Singapore November 2017 Special Issues in Treatment of Young Women with Breast Cancer Prudence Francis MD Peter MacCallum Cancer Centre Melbourne, Australia Conflict of
More informationThe Neoadjuvant Model as a Translational Tool for Drug and Biomarker Development in Breast Cancer
The Neoadjuvant Model as a Translational Tool for Drug and Biomarker Development in Breast Cancer Laura Spring, MD Breast Medical Oncology Massachusetts General Hospital Primary Mentor: Dr. Aditya Bardia
More informationOncotype DX testing in node-positive disease
Should gene array assays be routinely used in node positive disease? Yes Christy A. Russell, MD University of Southern California Oncotype DX testing in node-positive disease 1 Validity of the Oncotype
More informationBreast Cancer. Most common cancer among women in the US. 2nd leading cause of death in women. Mortality rates though have declined
Breast Cancer Most common cancer among women in the US 2nd leading cause of death in women Mortality rates though have declined 1 in 8 women will develop breast cancer Breast Cancer Breast cancer increases
More informationBreast Cancer. Saima Saeed MD
Breast Cancer Saima Saeed MD Breast Cancer Most common cancer among women in the US 2nd leading cause of death in women 1 in 8 women will develop breast cancer Incidence/mortality rates have declined Breast
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Accelerated Breast Irradiation and Brachytherapy Boost Page 1 of 27 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Accelerated Breast Irradiation and Brachytherapy
More informationTreatment Planning for Breast Cancer: Contouring Targets. Julia White MD Professor
Treatment Planning for Breast Cancer: Contouring Targets Julia White MD Professor Outline 1. RTOG Breast Cancer Atlas 2. Target development on Clinical Trials Whole Breast Irradiation 2-D Radiotherapy
More informationIndications and Technical Considerations for Adjuvant Radiation after Neoadjuvant Chemotherapy in Breast Cancer
Indications and Technical Considerations for Adjuvant Radiation after Neoadjuvant Chemotherapy in Breast Cancer Wendy A. Woodward, M.D. Ph.D. A sociate Profesor Section Chief, Breast Radiation Oncology
More informationTHE SURGEON S ROLE: THE AXILLA. Owen A Ung University of Queensland Royal Brisbane and Women s Hospital Wesley and St Andrews Hospital
THE SURGEON S ROLE: THE AXILLA Owen A Ung University of Queensland Royal Brisbane and Women s Hospital Wesley and St Andrews Hospital What are the concerns with treatment to the axilla Not necessary for
More information