PRONE BREAST WHAT S THE BIG DEAL? Rachel A. Hackett CMD, RTT

Transcription

1 PRONE BREAST WHAT S THE BIG DEAL? Rachel A. Hackett CMD, RTT

2 BREAST CANCER TREATMENT OPTIONS Surgical Options For the breast: Breast conserving surgery (lumpectomy) Breast Conservation Therapy = surgery + radiation Mastectomy +/- immediate reconstruction For lymph node assessment: Sentinel lymph node biopsy Axillary lymph node dissection

3 BREAST CANCER TREATMENT OPTIONS Systemic therapy options: Chemotherapy Can be given either before or after surgery Neoadjuvant or adjuvant Selection for use depends on stage and extent of disease, type of breast cancer and features (ER, PR, Her2 status), potential for down-staging to breast conservation, assessment of response Endocrine therapy / hormonal therapy Examples: tamoxifen, aromatase inhibitors, ovarian suppression

4 RATIONALE FOR RADIATION Role of radiation in the setting of breast conservation and post mastectomy: Improvement in local or locoregional control Survival benefit in invasive carcinomas and in the post mastectomy setting Disease free survival Overall survival

5 RADIATION TREATMENT OPTIONS TARGETS Whole breast Partial Breast Chest wall Regional nodes

6 RADIATION TREATMENT OPTIONS DOSE and FRACTIONATION Conventional Fractionation Gy per fraction to total dose Gy Hypofractionation Shorter course utilizing larger doses per fraction >2 Gy per fraction to lower total dose Gy given in daily fxs for whole breast Gy given twice daily fxs for partial breast Accelerated course Treatment over shorter time course

7 RADIATION TREATMENT OPTIONS MODALITIES: External Beam Photons Electrons Protons Brachytherapy Radioactive source Device Intraoperative Various means

8 RADIATION TREATMENT OPTIONS TECHNIQUES: Positioning Supine vs Prone CT simulation and volume based planning 3D conformal, e comp, IMRT Respiratory control with deep inspiration breath hold technique respiratory gating

9 RADIATION TREATMENT OPTIONS How is treatment tailored to the individual patient? Patient factors Treatment factors Disease burden Biology Risks for disease morbidity vs treatment morbidity

10 RADIATION TREATMENT OPTIONS Patient factors: age, comorbidities Treatment factors: type and extent of surgery, type of systemic therapy, response to neoadjuvant therapy Disease burden: T stage / size, N stage / # / ratio, ECE, LVSI, EIC, margins Biology: grade, ER, PR, Her2, gene profile

11 POSITIONING OPTIONS: Prone breast board Respiratory gating cube and glasses

12 USE OF RESPIRATORY GATING Free Breathing Breath Hold

13 RATIONALE FOR PRONE POSITIONING Prone position used for stereotactic core biopsy and breast MRI Technique adopted and modified for radiation treatment delivery

14 RATIONALE FOR PRONE POSITIONING Displacement of breast tissue away from chest wall and torso Minimize acute and late skin effects Minimize skin folds Particularly in women in large pendulous breasts High BMI/obesity Minimize dose to normal tissues Lung Heart Medical co-morbidities: underlying pulmonary disease (COPD, smoker), cardiac disease, collagen vascular disease, prior RT

15 USE OF PRONE POSITIONING Select patients with early stage disease Breast is target Minimize normal tissue doses and treatment toxicity

16 EARLY EXPERIENCES WITH PRONE MSKCC, USC, NYU, MCW, OSU, and others Whole breast Partial breast Concomitant boost Ongoing investigations for nodal regions, extended fields Lower lung doses Often lower heart doses Less skin toxicity No increased recurrences Reproducibility

17 THOUGHTS ON PRONE POSITIONING Thoughts on implementing prone positioning Important to have as an option for breast cancer treatment to minimize toxicity TEAM approach Requires active physician involvement and engagement throughout care (clinic, simulation, planning, verification, treatment) Learning curve

18 RTOG CONTOURING ATLAS Definitions: Breast contour: Clinical breast tissue Includes lumpectomy CTV Excludes pectoralis muscles, chest wall, ribs Chest wall contour: From skin to rib/pleural interface Includes pectoralis muscles, chest wall, ribs Breast + chest wall: For more locally advanced / high risk patients Regional nodal volumes White et al, RTOG Breast Cancer Contouring

19 BREAST CONTOUR

20 REGIONAL NODAL VOLUMES CONTOURS

21 PATIENT SELECTION FOR PRONE Other considerations: CTV Location Inner quadrants, particularly upper inner, can be challenging Anterior/skin extent Posterior extent of disease and proximity to chest wall/pectoralis muscles Select patients with early stage disease Breast is target Minimize normal tissue doses and treatment toxicity

22 PATIENT SELECTION FOR PRONE Early stage disease Stage 0, I, II Following breast conserving surgery Target = breast tissue not chest wall not lymph nodes not post-mastectomy

23 LIMITED NODAL COVERAGE WITH TANGENTS IN PRONE POSITION Csenka et al, Therapeutics and Clinical Risk Management 2014

24 LIMITED NODAL COVERAGE WITH TANGENTS IN PRONE POSITION Leonard et al, Radiation Oncology 2012

25 REVIEW OF BREAST MRI CAN BE HELPFUL

26 PATIENT SELECTION FOR PRONE Need to be able to get into the prone position and maintain stable position Arm and neck range of motion Back pain Agility and flexibility Body habitus Respiratory status Performance status Asking the patient about she tolerated prior biopsy procedure and / or MRI can be helpful

27 ASSESSMENT AT SIMULATION Physician presence to check set up wires, marks, positioning and reproducibility, anticipated tangent fields and heart and lung dose

28 OPTIONS TO MINIMIZE CARDIAC DOSE Beck et al, Frontiers in Oncology 2014

29 POSITIONING AND HEART LOCATION Huppert et al, Frontiers in Oncology 2011

30 CT-SIM SETUP ClearVue Prone Breast Board Indexed to CT-Sim couch and Linac couch Interchangeable for right and left breasts

31 CT-SIM SETUP Insert Options and Dimensions

32 CT-SIM SETUP Limited to 18cm of space between surface and base Rulers Vertical Horizontal

33 CT-SIM SETUP Step stool Patient push-ups Sheet size Pillow cases Keep horizontal ruler set

34 CT-SIM SETUP Wires Lumpectomy scar Nodal scar Midline Edge of both breast tissue Borders of breast tissue (2 cm margin)

35 Head turned toward ipsilateral side Creates a tripod position(minimize rotation) Body NOT rotated into opening Arms above head holding bars Knee roll cushion under ankles Patient moves so ML wire is palpable and visible in cutout opening Swipe contralateral breast out Keep couch lateral at 0 CT-SIM SETUP

36 CT-SIM SETUP Table is as low as possible Includes entire body contour SUP/INF position of breast centered in cutout CT angle of mandible to L3

37 CT-SIM SETUP

38 5 Tattoos 1 on breast Mid nipple Relatively flat 4 on back Lower straightening about 15-20cm inf the upper tattoo Avoid pants Laser at 0 Not necessarily midline Landmarks Most inf crease of neck Record rulers Vertical Horizontal CT-SIM SETUP

39 SETUP CHALLENGES Breast tattoo Too small not enough surface area Too irregular No stable area to place tattoo May have to put tattoo more posterior

40 SETUP UP CHALLENGES Breast hang is more than 18cm Use styrofoam Breast puddles on styrofoam

41 SETUP CHALLENGES Moving patients on the prone board Transfer sheets Patients rolling into cutout Neck pain Use cushion under head Patient movement to readjust Tried using warm rice bags

42 VERIFICATION DAY Wire contralateral breast with double solder wire Documents edge of treatment field Image all fields Daily PF for 1st week of treatment

43 TREATMENT SETUP

44 TREATMENT SETUP

45 Set table Couch lateral to zero Set horizontal ruler Patient moves into settings Swipe contralateral breast Triangulate Feel for sternum Bar pushed in so not treated through TREATMENT SETUP

46 Table raised to breast tattoo Gantry rotated to lateral reference Set SSD on breast tattoo Rotate gantry to lateral treatment field check treatment SSD TREATMENT SETUP

47 BBS + USER ORIGIN

48 DAILY TX ISO SHIFT

49 TX FIELDS

50 TX FIELDS ON SKIN

51 TREATMENT FIELDS

52 NORM POINT AND DOSE

53 ORTHOGS

54 ORTHOGS

55 MOSAIQ

56 3D-CRT, ECOMP, AND HYBRID IMRT Dosimetric Comparison of 3D-CRT, ECOMP, and Hybrid IMRT Plans for Prone Whole Breast Irradiation Haley Lowe, BA, Rachel Hackett C.M.D., Iris Wang Ph.D, Kilian Salerno M.D. Roswell Park Cancer Institute Buffalo, New York 20 patients post breast conservation surgery simulated in the prone position on a specialized prone breast board (10 right sided, 10 left sided) Dose prescription: 40 Gy in 15 fractions 3 treatment plans per patient were designed using Varian Eclipse 11 to treat the whole breast to the 95% isodose line

57 3D-CRT, ECOMP, AND HYBRID IMRT Plans were traditional 3D-CRT plan using wedges, ECOMP plan, and Hybrid IMRT where 2/3 of the daily dose is delivered with 3D-CRT and remaining 1/3 dose with forward planned IMRT Use of prone position for whole breast radiotherapy may achieve a significant reduction in lung and heart radiation dose when compared to traditional treatment in the supine position. Treatment delivery with ECOMP or a hybrid IMRT technique can further reduce heart and lung dose compared to 3D-CRT with wedges. Hybrid IMRT provides a significant reduction in maximum breast dose. ECOMP allows for the maximum decreases in mean heart dose while maintaining a relatively low maximum dose.

58 3D-CRT, ECOMP, AND HYBRID IMRT

59 3D-CRT, ECOMP, AND HYBRID IMRT Evaluation and dosimetric comparison of V20, heart dose and maximum dose for different prone whole breast irradiation planning techniques including 3D-CRT, ECOMP and hybrid IMRT.

60 3D-CRT, ECOMP, AND HYBRID IMRT Global maximum dose for all patients was reduced while maintaining dose homogeneity using both ECOMP and hybrid IMRT when compared to 3D-CRT. Maximum dose reduction using hybrid IMRT averaged a 1.3 Gy dose reduction compared to 3D-CRT planning. No difference in ipsilateral lung V20 was seen between the different planning techniques. Mean heart dose was reduced in the ECOMP and hybrid IMRT plans compared to the 3D-CRT plans. Hybrid IMRT reduced mean heart dose by 0.7 Gy for the right breast, 0.9 Gy for the left; ECOMP reduced mean heart dose by 2.2 Gy for the right, and 2.9 Gy for the left. There was no correlation found between the breast volume and maximum dose, ipsilateral lung V20, or mean heart dose.

61 IRREGULAR SURFACE COMPENSATORS

62 IRREGULAR SURFACE COMPENSATORS

63 IRREGULAR SURFACE COMPENSATORS

64 INHOMOGENEITY CORRECTION ON: OPT + CALC

65 EDIT FLUENCE - MAKE IT FLASHY

66 RESULT OF DOSE CALCULATION

67 LACK OF TANGENTIAL DOSE

68 PRESCRIBE DOWN PAINT OUT THE HOT

69 HEART DOSE

70 HEART AVOIDANCE

71 LUNG DOSE REDUCED A LOT

72 LUNG DOSE REDUCED A LOT

73 THANK YOU! Kilian Salerno, MD Simon Fung-Kee-Fung, MD Maria Durlak, RTT