External beam radiotherapy

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24.04.13
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External beam radiotherapy

• Whole Breast Radiotherapy
• (WBRT)

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Standard tangential field
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Simulation
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Radiotherapy For Breast Cancer Increases Heart
Disease Risk
N Engl J Med 2013 3681055-1056March 14, 2013
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FATIGUE
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RADIATION DERMATITIS
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RADIATION DERMATITIS
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Changes in breast appearance
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Rib fractures
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LYMPHEDEMA
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Conventional Whole breast Radiotherapy plan
Boost
2Gy per fraction
25 fractions
8 fractions
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FASTER, FASTER!
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The UK standardisation of Breast Radiotherapy
(START)-Trial A and B of Radiotherapy
hypofracyionation for treatment of early breast
cancer a randomized trial
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Hypofractionation

• START
• 25 ? 2 Gy 15 ? 2,67 Gy

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START
Randomization
50 Gy- in 25 fractions
40 Gy- in 15 fraction
1105
1110
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HypofractionatedRadiation Therapy for Breast
Cancer
RANDOMIZATION
50 Gy in 25 fractions
42,5 Gy in 16 fractions
612
622
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Shorter fractionation schedules

• No difference in local recurrence
• No difference in overall survival
• A significant decrease in acute radiation
  toxicity
• No difference in late skin toxicity, ischemic
  heart disease, or rib fractures
• No difference in breast appearance

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What still is questionable?

• The effect not clear in large breasts
• The safety of shorter course in combination with
  chemotherapy or monoclonal antibodies (Herceptin,
  Pertuzumab)?
• The boost issue
• What about treatment for regional lymph nodes ?

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Reasonable approach (supported by ASTRO/ESTRO)

• Women gt50y
• Tumor lt 5 cm
• Node negative
• Without prior chemo?
• Boost?

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Partial Breast Irradiation
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Rationale for Partial Breast Irradiation

• 80 of local recurrences after conservative
  surgery WBRT occur in tumor bed region
• Elsewhere recurrences in breast rare after CS
  /- WBRT

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Partial Breast Radiotherapy
Mammosite
Interstitial Breast Brachytherapy
5 days-2 daily fractions
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Intra-operative radiotherapy
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External Beam Partial Breast Irradiation
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PBI Where are we?

• While several preliminary studies have had
  excellent 5-yr results, they contain only small
  numbers of highly-selected pts
• NSABP B-39/RTOG 10 yrs for data to mature

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Consensus Statements on PBI American Society of
Breast Surgeons and American Brachytherapy
Society.

• PBI off protocol should be limited to pts
• age gt 50
• IDC histology or DCIS
• Tumor lt 2 cm (including DCIS)
• Margin gt 2 mm
• Lymph node - negative

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Partial Breast Irradiation Not Yet the
Standard-of-Care
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