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 for breast conserving therapy. 2. Describe the different ways of delivering radiation as part of breast conserving therapy. 3. List patient and tumor factors that are important in determining a patients suitability for Breast Conserving Therapy. 4. Describe the various ways and processes of delivering radiation as part of breast conserving therapy. 2
Early Stage Breast Cancer NCI Definition: cancer that has not spread beyond the breast or the axillary lymph nodes. This includes ductal carcinoma in situ and stage IA and IB, most stage IIA, stage IIB, and some stage IIIA, breast cancers. 3
Early Stage Breast Cancer by NCI definition is all but Stage 4, but we ll be focusing on Stage 0-1. 4
Historical management of the breast in breast cancer Halstead Mastectomy included removal of breast, pectoralis muscles and axillary lymph nodes. Modified Radical Mastectomy spares pectoralis muscles and some axillary lymph nodes. Partial Mastectomy with or without lymph node sampling (SLN) and Radiotherapy. 5
Patients undergoing partial mastectomy are those receiving radiotherapy and are the basis of this presentation. 6
Factors influencing treatment choice. Patient factors Tumor factors 7
Patient Factors Age at diagnosis Performance Status Work or Distance factors Co-morbidities Previous Medical History Choice 8
Tumor Factors Size Location Grade Stage 9
Radiation Treatment Options for Local Management in breast conserving therapy. Standard External Beam RT Hypofractionated Canadian External Beam RT Prone Breast Deep Inspiration Breath Hold Accelerated Partial Breast RT (APBI) Intraoperative RT (IORT) 10
1950 - Present 1992 - Present 2000 - Future 6-7 weeks of treatment 5 days twice a day As little as 8 min. during surgery WBRT APBI IORT
Standard RT Pioneered by NSABP trials Daily radiation to entire breast 5 days a week for 6 to 6.5 weeks. Treatment given 180-200 cgy per day for 5 weeks. Boost to tumor site given for and additional 5 to 8 days. All patients are candidates for this that are candidate for BCT. 12
Standard Whole Breast RT
Beam Modifications to improved tissue homogeneity of Dose. Uncompensated beam Conpensated beam with wedge 14
LT BREAST Conventional Plan 5040cGy UNCOMPENSATED Beam
LT BREAST Wedges
ASTRO Breast Guideline 2018 for Whole Breast Irradiation (WBI) The purpose of this guideline is to offer recommendations on fractionation for whole breast irradiation (WBI) with or without a tumor bed boost and guidance on treatment planning and delivery. 17
ASTRO Breast Guideline 2018 The American Society for Radiation Oncology (ASTRO) convened a task force to address 5 key questions focused on dose-fractionation for WBI, indications and dose-fractionation for tumor bed boost, and treatment planning techniques for WBI and tumor bed boost. Guideline recommendations were based on a systematic literature review and created using a predefined consensus-building methodology supported by ASTRO-approved tools for grading evidence May 14, quality 2018 and recommendation strength. 18
ASTRO Breast Guideline 2018 For women with invasive breast cancer receiving WBI with or without inclusion of the low axilla, the preferred dosefractionation scheme is hypofractionated WBI to a dose of 4000 cgy in 15 fractions or 4250 cgy in 16 fractions. The guideline discusses factors that might or should affect fractionation decisions. Use of boost should be based on shared decisionmaking that considers patient, tumor, and treatment factors, and the task force delineates specific subgroups in which it recommends or suggests use or omission of boost, along with dose recommendations. 19
ASTRO Breast Guidline 2018 WBI represents a significant portion of radiation oncology practice, and these recommendations are intended to offer the groundwork for defining evidence-based practice for this common and important modality. This guideline also seeks to promote appropriately individualized, shared decision-making regarding WBI between physicians and patients. 20
Hypofractionated Radiation Therapy Canadian Fractionation Daily RT 5 days week 266 cgy per day for 16 days Boost to lumpectomy site 4-5 days. Total duration 4+ wks vs 6+ weeks. Not used in lymphnodal RT to be given Breast can be too large to get good homogeneity in dose requiring a more standard apporach. Adoption has been slow, but increasing.» Improvement in Dose distribution with beam modifiers. 21
WBRT HYPO- FRACTIONATED
Strategies to Reduce Dose to the Heart. Deep Inspiration Breath Hold (DIBH) RT Prone Breast RT 23
WBRT - DIBH
WBRT PRONE POSITIONING
Accelerated Partial Breast RT Radiation to tumor cavity only partial breast Treated 2 times per day accelerated seperated by 6 hours. 340 cgy each fraction for total of 10 days. Primarily done by balloons being inserted into tumor cavity at time of surgery. Planning is done and radioactive sources are delivered to the center of the balloon to give treatment. 26
APBI Treatment takes about 15 minutes. Treatment over in 1 week. Can be done by external beam RT, but rarely done so. NOT all Patients and NOT all tumors are candidates. 27
PARTIAL BREAST - SAVI HDR
ASTRO and Soc. Surg. Onc. Guidelines for APBI Suitability. Suitable Cautionary Unsutiable 29
Suitable Age greater than 50, No BRCA1/2 mutation Tumor less than 2 cm (T1 or Tis) 2mm (-) margins for invasive dz, no LVSI, ER+ Unicentric and Unifocal Invasive or other favorable Subtypes DCIS margin should be 3mm or more, No EIC pn0 No Neoadjuvant therapy. 30
Cautionary 40 to 49 if all other critera are suitable 50 or higher if have one of the adverse pathological factors. 31
Unsuitable Less than 40 Tumor greater than 3 cm +margin +LVSI, +nodes Multicentric or multifocal greater than 3 cm. Large DCIS (greater than 3cm) or EIC. 32
Intraopertiave Radiation Therapy IORT 33
Intraoperative RT (IORT) Single treatment given in the OR After successful removal of tumor balloon is placed in cavity of tumor. Ultrasound performed to make sue there are no air pockets and the the distance of the balloon surface to skin and chest wall is adequate. A catheter is then attached to the balloon where the radiation will travel to deliver dose. 20 Gray is given in one dose. 34
IORT
Who is a candidate for IORT Guidelines? Current Xoft Axxent ebx IORT System Trial criteria. -older than 40, not pregnant -tumor less than 3 cm, -Invasive Ductal or Ductal Carcinoma-in-situ -Unifocal disease -Node negative, no LVSI -No previous cancer or XRT -BRCA-1 and 2 carriers, excluded. 36
No Modifications to the OR
Tumor Removal and Cavity Evaluation MC418R1 4/12
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ebx Controller Components Display Screen/ Touch Screen Control Handheld Barcode Scanner Adjustable arm (in storage position) Well Chamber Wheel Brakes
Miniaturized X-ray Tube : The Electronic Brachytherapy Source The Source Operates at 50 kv and 300 microamps (15 Watts) MC418R1 4/12
ebx High Dose, Low Energy Delivers Less Radiation to Critical Structures (heart, lung) Dickler, et al. A dosimetric comparison of MammoSite high dose rate brachytherapy and Xoft Axxent electronic brachytherapy, Brachytherapy (6) 2007, 164-168.. Slide courtesy of Dr. David Wazer MC418R1 4/12
Future Directions Trend to use shorter courses of XRT Use of molecular tumor markers to help select patients for treatment modality Possible omission of XRT in certain patients? 43
Some of the B Team at FS@LRC Questions?? 44