Radiotherapy in Breast Cancer: Current Issues
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BREAST CANCER RADIOTHERAPY: CURRENT ISSUES
Dr Jyotirup Goswami
Department of Radiotherapy
Westbank Hospital
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The more things change, the more they remain the same:
The target, dose, fractionation and delivery modalities are all changing in breast cancer.
Yet, some of the key questions of yesterday still remain!
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NEW STANDARDS OF CARE INRADIOTHERAPY OF BREAST CANCER
Whole breast RT followed by tumor bed boost APBI Conformal RT IMRT & VMAT Hypofractionated RT Changing indications for post-mastectomy
radiotherapy (chest wall & nodal) Prone breast RT
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BCS+RT
Mastectomy is no longer a standard of care in breast cancer surgery
BCS is possible in all EBC and is also practised in LABC
Whole breast RT is compulsory in BCT Results of BCS+RT and mastectomy are
equivalent Local control rates are also significantly
improved by use of boost to tumor bed
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BCS+RT VS MASTECTOMY: RCTSInstitute IGR Milan NSABP
B-06NCI EORTC Danish
Stage 1 1 1,2 1,2 1,2 1,2,3
Surgery 2cm gross
margin
Quad-rantectom
y
Lump-ectomy
Gross excision
1 cm gross margin
Wide excision
Follow-up(y) 15 20 20 18 10 6
OS:BCS+RT(%) 73 42 46 59 65 79
M(%) 65 41 47 58 66 82
LR: BCS+RT(%) 9 9 14 22 20 3
M(%) 14 2 10 6 12 4
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BCS+RT VS BCS
Vinh-Hung et al. JNCI ( 2004);96:115-121
The pooled meta-analysis of 15 RCTs shows a threefold reduction in local failure & a small but significant improvement in OS with RT after BCS
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EBCTCG META-ANALYSIS (LANCET 2000)
Meta-analysis of 10 and 20 yr results of 40 RCTs of EBC.
N=20 000 50% node positive Local recurrence
after BCS was reduced by approximately 2/3 with RT, irrespective of type of RT and stage.
Breast cancer mortality was significantly reduced
However, mortality due to other causes was significantly increased.
Absolute increase in 20-yr survival was 2-4% (except those women at very low risk of recurrence).
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EBCTCG META-ANALYSIS (LANCET 2005)
78 RCTs of EBC. N= 42 000 7300 had BCS Local recurrence
rate at 5 years, after BCS was reduced by post-op RT from 26% to 7%.
15-yr breast cancer mortality was significantly reduced, from 35.9% to 30.5%
Overall mortality reduction with RT was 5.3% at 15-yrs.
Similar proportional benefit of RT in ALL stages. Absolute benefit varies with the actual risk, according to stage.
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BREAST CONSERVATION THERAPY: NODE NEGATIVE DISEASE
EBCTCG Lancet 2005,vol 366, 2093
5 yr gain 16.1%
15 yr gain 5.1%
LR OS
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EBCTCG Lancet 2005,vol 366, 2093
5 yr gain 30.1%
15 yr gain 7.1%
LR OS
BREAST CONSERVATION THERAPY:
NODE POSITIVE DISEASE
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EBCTCG META-ANALYSIS (LANCET 2011)
17 RCTs of BCS+RT vs BCS alone
N= 10 801 (pN0=7287, pN+=1050)
ANY recurrence rate at 10 years, after BCS was reduced by post-op RT from 35% to 19.3%.
15-yr breast cancer mortality was significantly reduced, from 25.2% to 21.4%
Similar proportional benefit of RT in ALL stages. Absolute benefit varies with the actual risk, according to stage.
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BOOST VS NO BOOSTEORTC 22881-10882 TRIAL
Bartelink et al
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Planning of boost is largely dependant on localisation method and modality used
Many centres practise clinical planning, especially if electrons are to be used
CT based planning, though preferable, is also problematic
Cavity location is not always clear.
Also the shape and size of the cavity will change, depending on when the image is taken
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SEROMA CONTOURING GUIDELINES
STV (Seroma Target Volume)= tumor cavity
CTV= STV+1cm (EDITED from skin and chest wall by 5mm)
PTV=CTV+1cm
STV to EXclude breast tissue stranding, but INclude surgical clips (if present)
Wong et al
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BOOST MODALITIES
En-face electrons HDR brachytherapy 3DCRT/IMRT/VMAT IMPT Modulated electrons (MERT)
Electrons are still the commonest and simplest modality. But dosimetrically the most inferior!
HDR brachytherapy is a labour intensive, cosmetically demanding, but dosimetrically excellent alternative for deep-seated tumors. (>3cm from skin)
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BOOST DOSIMETRYDE VS MET VS VMAT
Alexander et al
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BREAST CONTOURING GUIDELINES
Because more and more centres are doing conformal CT-based planning for breast cancer, contouring guidelines for the intact breast/ chest wall are also increasingly necessary.
The RTOG has come up with a Breast Cancer Atlas.
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BREAST CANCER ATLAS
For IIB/III after
NACT & BCS
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REGIONAL NODAL CONTOURING
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DURING CT SIMULATION
Post-BCS
Post-Mastectomy
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Breast-superior
Breast-inferior
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SCF begins
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Axillary level III begins
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Axillary level II begins
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Axillary level I begins
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Axillary level I ends
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IMC begins
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IMC ends
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APBI
Twin rationale:
(1) Most breast cancer recurrences occur in the index quadrant.
(2) Many patients cannot come for prolonged 5-6 week adjuvant radiotherapy for logistic reasons.
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APBI: INDICATIONS (ASTRO RECOMMENDATIONS)
Suitable outside clinical trial
(ALL of) Age>60 years BRCA negative T1N0M0 (pT<2cm) EIC negative Unifocal IDC/ favourable
histology Margin negative (>2mm) LCIS negative ER positive
Suitable only in a clinical trial
(ANY of) Age 50-59 years BRCA negative T1/2,N0,M0 (pT2-3 cm) EIC <3cm Unifocal ILC Margin close (<2mm) ER negative
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ASTRO: “UNSUITABLE” FOR APBI
ANY OF:
T>3cm/T4 or N+ BRCA mutated High grade LVSI extensive EIC+ve (>3cm) Multifocal disease (contraindication to BCS
per se) Margin positive Received neoadjuvant chemotherapy
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APBI: MODALITIES
Intra-operative electrons (ELIOT) Intra-operative/ peri-operative HDR
interstitial brachytherapy Mammosite Intra-operative orthovoltage X rays (TARGIT)
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75432 1112101620
APBI: INTERSTITIAL BRACHYTHERAPY
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3D CONFORMAL BRACHYTHERAPY
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TARGIT
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ELIOT
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3DCRT AND IMRT
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MAMMOSITE
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COMPARISON OF APBI TECHNIQUES
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APBI: CLINICAL RESULTS SO FAR
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HDR INTERSTITIAL BRACHYTHERAPY:RESULTS
Institution
Dose Dose Rate
Ipsilateral breast
recurrence rate
Cosmesis & Complications
William Beaumont Hospital, USA
32-34 Gy/8-10#
50 Gy
HDR
LDR
2.1% (5-yr)
0.9% (5-yr)
>90% achieved good to excellent cosmesis
Ochsner Clinic, USA
32-34 Gy/8-10#
50 Gy
HDR
LDR
8% 75% achieved good to excellent cosmesis
London Regional Cancer Centre, Ontario, Canada
37.2 Gy/10#
HDR 16.2% at 5 yrs*
Median overall cosmetic score 89%.
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HDR INTERSTITIAL BRACHYTHERAPY:RESULTS
Institution
Dose Dose Rate
Ipsilateral breast
recurrence rate
Cosmesis & Complications
National Institute of Oncology, Hungary
30.3-36.4 Gy/7#
HDR 6.7% Excellent to good cosmesis in 84.4%.
Tufts New England, USA
34 Gy/10#
HDR 6.1% (5-yr actuarial)
89% had excellent cosmesis at 5 years.
Guy’s Hospital, London
55 Gy LDR 37%* Cosmesis good to excellent in 85%.
*= inappropriate selection of patients for APBI
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MAMMOSITE:RESULTS
Institution Dose Ipsilateral breast
recurrence rate
Cosmesis &Complications
American Society of Breast Surgeons Mammosite Breast Brachytherapy Registry trial (97 institutions)
34 Gy/10#
1.79% 3-yr actuarial LRR
Good-excellent cosmesis in >93%.
Rush University Medical Centre, Chicago, USA
34 Gy/10#
5.7% (crude)
Good-excellent cosmesis in 93%.
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IORT:RESULTS
Institution
Dose Modality Ipsilateral breast
recurrence rate
Cosmesis & Complications
European Institute of Oncology, Milan
21 Gy Electrons 1% Mild/severe fibrosis in 3%.
State University of Buffalo, USA
15-20 Gy 120 kV X rays
29% Acceptable
University College, London(TARGIT)
20 Gy 50 kV X rays
0% Acceptable
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EBRT (3DCRT): RESULTS
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PROSPECTIVE RCTS OF APBI
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IMRT BREAST: WHY?
Dosimetric advantages include:
(1) better dose homogeneity for whole breast RT
(2) better coverage of tumor cavity(3) feasibility of SIB
Forward planned IMRT (field-in-field) is preferred as it is simple and effective.
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FORWARD PLAN IMRT
Courtesy: Budrukkar A
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IMPORT TRIALS (PHASE III RCTS FROM UK)
IMPORT High: (2008-ongoing) To test dose-escalated IMRT
in high-risk EBC after BCS High risk by v/o (ANY)
N+/grade III/T>2/NACT received/margin<5mm/age 18-49 yrs/LVE+
3 arms: WBRT followed by sequential
boost (56 Gy/23#) WBRT with SIB (48Gy/15#) WBRT with SIB (53Gy/15#)
Primary endpoint: Breast fibrosis
IMPORT Low: (2006-2010) To test PBI by IMRT in low-
risk EBC after BCS (ALL) IDC/no ILC/pN0/no
LVE/pT<3cm/unifocal/grade I,II or III/margin>2mm
3 arms: WBRT (15#/3 weeks) WBRT +PBI (each 15#/3
weeks) PBI (15#/3 weeks)
Primary endpoint: Local control (ipsilateral)
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HYPOFRACTIONATED RT
Started as an empirical practice in government-run health care systems of UK and Canada
Initially, a purely logistical exercise to reduce treatment duration & create machine space
Recently, 2 large trials, START-A and START-B, have validated that clinically as well, hypofractionated RT is safe and effective.
In fact, even while delivering a lower BED, the hypofractionated regimens have shown a survival advantage over conventional fractionation!
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START-A: (1998-2002) N=2236 EBC (pT1-T3a, pN0-N1,
M0) BCS=1900 (85%) &
MRM=336 (15%)3 arms: 50 Gy/25#/5 weeks 41.6 Gy/13#/5 weeks 39 Gy/13#/5 weeks
Median FU=5.1 years
Locoregional relapse rates were 3.6%, 3.5% and 5.2%, respectively
Late effects, based on photographs and patient assessments, were significantly lower with 39 Gy as compared to 50 Gy
This trial estimated α/β of breast cancer as 4.6Gy for tumor control and 3.4Gy for late change in photographic appearance.
Lancet Online. March 19,2008
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START-B: (1999-2001) N=2215 EBC (pT1-T3a, pN0-N1,
M0) BCS=2038 (92%) &
MRM=177 (8%)2 arms: 50 Gy/25#/5 weeks 40 Gy/15#/3 weeks
Median FU=6 years
Locoregional relapse rates were 3.3% and 2.2%, respectively
Absolute differences in locoregional relapse was -0.7% (95%CI -1.7% to 0.9%), meaning that with 40Gy the relapse rate would be at most 1% worse and at best 1.7% BETTER!
Lancet Online. March 19,2008
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HYPOFRACTIONATION FROM THE RADIOBIOLOGIC VIEWPOINT
UK-FAST: (2004-2007) N=915 Favourable EBCs after
BCS (age>50 yrs, pT<3cm, pN0)
3 arms: 50Gy/25$/5 weeks 28.5Gy/5#/5 weeks
(once-weekly) 30Gy/5#/5 weeks (once-
weekly)
Median FU=37.3 months
Primary end-point was 2 yr change in photographic appearance of breast
3-yr physician assessed moderate to marked breast adverse effects were 9.5%, 11.1% and 17.3% respectively.
Conclusion:At 3 yrs median FU, 28.5Gy/5# (@5.7Gy/#) is comparable to 50Gy/25# for breast adverse effects and significantly milder than 30Gy/5# (@6Gy/#)
Radiotherapy & Oncology. Epub.2011
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CHANGING INDICATIONS OF PMRT
New indications include: Any AXLN +ve High grade tumors LVE PNI Age <45-50 years pT>2cm
Scoring systems are often used.
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PN1 VS PN2 FOR CHEST WALL RT
Classically, pN2 disease (>=4 positive axillary nodes) was the indication for postmastectomy chest wall RT
Subgroup analysis of the DBCG 82 b&c trials (2007) suggested SIMILAR survival benefit of PMRT for 1-3 vs 4+ LN.
The St Gallen Consensus (2007) is to treat the SCF even for pN1 (1-3 positive axillary nodes)
The SUPREMO trial evaluated the benefit of PMRT in 1-3 axillary lymph node positive patients.
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SUPREMO TRIAL(SELECTIVE USE OF
POSTOPERATIVE RADIOTHERAPY AFTER MASTECTOMY)
Started 2006. Expected to complete end-2012.
N=1600 (planned); 1295 randomised so far*
pT1-T3 (+/- multifocal ds), pN0-N1 (not more than 3 AXLN positive), M0 ,post-MRM
No bilateral breast cancer, margins clear (at least 1mm), no IMC nodes
Chemotherapy as required
2 arms: Standard RT to chest wall &
SCF Observation
Objective: To determine the overall survival of intermediate risk patients treated with post-op RT
Primary endpoint: OS, acute & late morbidities
Secondary endpoints: Locoregional recurrence rates, metastasis-free survival, DFS, QoL, cost-effectiveness
*personal communication
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IS THERE A ROLE OF AXILLARY NODAL RT?
Axillary nodal RT is no longer indicated if complete axillary dissection (>10 LN sampled) has been performed.
Axillary nodal RT significantly adds to the lymphoedema morbidity
The only possible indications today are: (1) incomplete/ no axillary dissection (2) positive axillary nodes WITH
extracapsular extension (ECE)/ perinodal extension (PNE)
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IS SCF RT REQUIRED AT ALL?
Studies suggest that isolated SCF recurrences are uncommon, for both pN1 and pN3 disease
The main risk for pN3 disease, is not SCF recurrence but distant metastasis
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PRONE BREAST RT Suitable for pendulous
breasts, where breast-only RT is required.
Results in significantly better coverage of the breast and significant reduction of dose to the ipsilateral lung.
Heart dose remains unchanged.
BUT there is significantly more grade 1-2 dermatitis AND setup error.
Varga et al
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THANK YOU