Recent advances in Breast Radiotherapy - Dr ... - Parkside Hospital

Recent advances in Breast Radiotherapy - Dr ... - Parkside Hospital

The Royal MarsdenRecent Advances inBreast RadiotherapyDr Anna KirbyConsultant Clinical Oncologist

2The Royal MarsdenOverview: Key innovations1. 2D to 3D planning2. Hypofractionation3. Intensity modulated radiotherapy4. Tumour bed localisation5. Heart-sparing breast radiotherapy6. Risk-adapted radiotherapy7. Intra-operative radiotherapy

3The Royal MarsdenOverview: Key innovations1. 2D to 3D planning2. HypofractionationIncreasing efficacy3. Intensity modulated radiotherapy4. Tumour bed localisationReducing side-effects5. Heart-sparing breast radiotherapy6. Risk-adapted radiotherapy7. Intra-operative radiotherapy

The Royal Marsden2D-planned radiotherapyPrimaryBeam

The Royal MarsdenPotential for missing tumour bed

The Royal MarsdenPotentially large normal tissue doses

The Royal Marsden2D vs 3D radiotherapy dose distributionsCourtesy: Ellen Donovan

The Royal MarsdenFull 3D optimisation

The Royal Marsden3D planning: the benefits• Increases accuracy• Allows optimisation of breast coverage vs normaltissue doses• Reduces late side-effects including breast shrinkage,firmness, pain and rib fracture• 80% of UK RT centres offer 3D dose optimisation(RCR audit 2012)

The Royal MarsdenHypofractionation

The Royal MarsdenSTART TrialSTART Trial BTrial BN= 221550Gy in 25 #(2.0Gy) 5 wksN=110540Gy in 15 #(2.67Gy) 3 wksN=11106.0 years median follow-up

The Royal MarsdenTrial B : Local-regional (LR) tumour relapse% of patients withno LR relapse1007540 Gy (29 / 1110)50 Gy (36 / 1105)Cumulative hazard rate0.040.0350 Gy50250.020.0140 Gy00 1 2 3 4 5 6Years since randomisationNumber at risk:Yr 0 Yr 1 Yr 2 Yr 3 Yr 4 Yr 5 Yr 62215 2158 2098 2007 1903 1589 8840.000 1 2 3 4 5 6Years since randomisationHazard Ratio (95%CI)Absolute difference at 5 yr (95%CI)40 Gy vs. 50 Gy 0.79 (0.48 – 1.29) -0.6% (-1.7% – 0.9%)

The Royal MarsdenTrial B: Change in breast appearance% of patients with no changein breast appearance100755040 Gy/15F (145 / 462)50 Gy/25F (167 / 461)2500 1 2 3 4 5Years since randomisationNumber Yr 0 Yr 2 Yr 5at risk: 923 914 512Hazard Ratios(95%CI)Absolute difference at 5 yr (95%CI)40 Gy vs. 50 Gy 0.83 (0.66 – 1.04) -5.6% (-11.8% – 1.2%)

40Gy vs. 50GyThe Royal MarsdenTrial B : Late normal tissue effectsPATIENT self-assessment(moderate or marked)PHYSICIAN assessment of(moderate or marked)40Gy better50Gy better40Gy better50Gy betterShrinkageHardnessSkinappearanceBreastappearanceSwellingShrinkageIndurationTelangiectasiaOedema.15 .5 1 2Hazard Ratio (95% CI).15 .5 1 2Hazard Ratio (95% CI)

The Royal MarsdenStandard RT Regimens are ChangingTotal dose(Gy)NumberfractionsFraction size(Gy)Time(weeks)InternationalStandardNew UKStandard50 25 2.0 540 15 2.67 3

The Royal MarsdenAdvantages of hypofractionated breast RT• Reduced acute and late side-effects• Trend towards greater efficacy• Easier to integrate with surgery & systemictherapies• More convenient for patients

The Royal MarsdenIntensity modulatedradiotherapy (IMRT)

The Royal MarsdenSimple forward-planned IMRT:“step and shoot”Open FieldSegmented Field

The Royal MarsdenSimple forward-planned IMRT:“step and shoot”

The Royal MarsdenInverse-planned IMRT• Pectus excavatum• Internal mammary chain• Bilateral breast RT

The Royal MarsdenVolumetric modulated arc therapy

The Royal MarsdenTumour bed localisation

The Royal MarsdenTumour bed localisationCavity visualisation scores1 2 3 4 5Landis et al, IJROBP, 2007?

The Royal MarsdenOncoplastic surgery: scar ≠ tumour bed

The Royal MarsdenMarker-based tumour bed localisationIMPORT HIGH Trial Planning Pack

The Royal MarsdenBoost planning based on markersClipsSkin entry pointExcision cavityIMPORT High Trial, RMH Sutton

The Royal MarsdenHeart-sparing radiotherapy

The Royal MarsdenAddition of RT to BCS improves localcontrol & survivalEarly Breast Cancer Triallists’ Collaborative Group, Lancet, 2005

The Royal Marsdenbut increases non breast cancermortalityEarly Breast Cancer Trialists’ Collaborative Group, Lancet, 2005

The Royal MarsdenStandard tangents often result in high dosesto cardiac tissues esp LADCourtesy: Jane Dobbs

32The Royal MarsdenNCRI Conference, Liverpool 06.11.2012Heart-sparing breast RT techniquesMultileaf collimation (MLC)IMRTProneBreath-hold

33The Royal MarsdenNCRI Conference, Liverpool 06.11.2012UK HeartSpare Study (NIHR funded)ABC_DIBHv_DIBHvsDigital spirometer Monitoring VisualGood data Reproducibility Data lackingExpensive Cost Cheap

34The Royal MarsdenNCRI Conference, Liverpool 06.11.2012HeartSpare: Example of heart-sparingachieved in breath-holdFree breathingv_DIBH ABC_DIBH

The Royal MarsdenRisk-adapted radiotherapy

The Royal MarsdenRisk-adapted radiotherapyHolland et al, Cancer 1985

The Royal MarsdenIMPORT HIGH dose escalation study2.4Gy2.7Gy3.2Gy15 Fractions(3 weeks)Courtesy: Dr C Coles, Addenbrooke’s Hospital

The Royal MarsdenBrings together advances in planning,fractionation & localisation3fld boost5fld boost

The Royal MarsdenRequires real time verification ofposition of tumour bed markersRT beamCone beamimaging

The Royal MarsdenTumour bed clips make automated set-uppossible1 st day of RTCone beamPlanning CTAdjustedIMPORT High Trial, RMH Sutton

The Royal MarsdenPartial breast radiotherapy

The Royal MarsdenPartial breast irradiation techniques• Intraoperative techniques• Intrabeam (TARGIT)• ELIOT (Italy)• Post-operative techniques• Mammosite (US)• External beam RT (UK and US)

The Royal MarsdenIntrabeam (TARGIT)• Intra-operative RT• 50kV photons via 3.2mm diam tube for 25-30mins• >45yrs, eligible for BCT• Mean FU 60mths,• 5yr LRR 1.7%Vaidya et al, IJROBP 2011

The Royal MarsdenMammosite• Post-operative• Balloon• 30% seroma rate,10% infection rate,90% good cosmesisat med FU of 72mthsVicini IJROBP 2011

The Royal MarsdenExternal beam partial breast irradiation• Treats 25mm marginaround tumour bed• Full path reportavailableColes &Yarnold, UK

The Royal MarsdenPartial breast irradiation• Currently available in trial setting only• Awaiting long-term follow-up of a number of studies• Likely to be available to limited subgroups of womenin the medium term

47The Royal MarsdenChange Presentation title and date in Footer in breast RT: what do thesemean for your patients?• Most women can be treated in 3-4 weeks withreduced risk of late-side effects due to• Homogeneous 3D-doses• Reduced total dose to normal tissues• Use of heart-sparing techniques• Accuracy of treatment is within mm due to• 3D anatomical information• Tumour bed markers

The Royal MarsdenThe future of breast radiotherapy• Ongoing studies in risk-adapted radiotherapy aim toindividualise treatment further• Improved imaging techniques will help guide use ofnodal irradiation• Likely to be delivering less RT in future• Either less tissue treated• Or no RT• Indications for intra-operative radiotherapy likely toincrease

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