RADIOTHERAPY IN

CARCINOMA BREAST

DR SAILENDRA
SENIOR RESIDENT
DEPT OF RADIOTHERAPY
MAULANA AZAD MEDICAL COLLEGE
 INTRODUCTION
• Breast cancer is one of the most commoncancers seen
and treated byradiation oncologists.
• Radiation playsan important role in the managementof
breast cancer at all stages including ductal carcinoma in
situ, early-stage disease (as acomponent of breast
conservation), and locally advanceddisease (as an
adjuvant treatment after mastectomy).
• Radiation is also ahighly effective palliative
modality.
 RATIONALE

• MOST COMMON SITE OFRECURRENCEIS THE

LOCALSITE
• PREVENTING RECURRENCEALSOIMPROVES
THEQUALITY OF LIFEAND OVERALL SURVIVAL
• NOTALLRECURRENCESARESALVAGEABLE
 WHEN TOGIVE RT
• POSTBCS
• POST
MASTECTOMY
• PALLIATIVE
• NEOADJUVANT
 Indiacations of wholebreast
radiotherapy
• Tumour size>5cm
• Nodepositive
• All casesof BCS
• Positive or Closemargin
Can be considered in high risk cases(not proved in prospective
randomised trials)
• Highgrade
• Young
• LVSI
• Inadequate nodal dissection
• Tripple negative receptor status
• Her-2 positivetumours
• Skin,nipple or pectoralis muscleinvasion
 Indications of axillary nodalirradiation
• N+with extensiveECE
• SLN+with nodissection
• Inadequate axillarydissection
• High risk with nodissection

High risk is defined as estimated probability of nodal involvement greater than 10% to 15%
 Indications of SCLNirradiation
• Clinical N2 or N3disease
• >4+LNafter axillarydissection
• 1–3 +LNwith high riskfeatures
• Node +sentinel lymph node with no dissection unless risk of
additional axillary disease is verysmall
• High risk no dissection

• The impact of supraclavicular RTon overall outcome has

never been examinedin anyrandomised trial separately from
IMN RT.
 Indications of IMNirradiation
• Internal mammarynode (IMN) metastases
• 5%----negative axillary nodes
• 20%to 50%-----with positivenodes.
• Clinical IMN recurrence occurs in 1%or fewer patients in nearly
all studies
• Positive axillary nodes with central and mediallesions
• Stage III breastcancer
• +SLN in the IM chain
• +SLN in axilla with drainage to IM on
lymphosintigraphy
• Clinically positive IMLN
 TECHNIQUE FORRADIOTHERAPY
• Positioning
• Immobilization
• Simulation
• TargetVolume
• TreatmentPlanning
• Dose& Fractionation
• Set Up Verification and treatment delivery
 PATIENTPOSITIONING AND
IMMOBILISATION
• Positioning & Immobilization most crucial parts
of RTtreatment for
– accurate delivery of aprescribed radiation dose
– sparing surrounding critical tissues
• Primarygoal:
– Reproducibility of position
– reduce positioning errors
– canreduce time for daily set up
 PATIENTPOSITIONING AND
IMMOBILISATION
• Supine or proneposition
• Arms abducted and externally rotated to 90or 120 degree.
• Prone position is Suitable for pendulous breasts, where breast-
only RTis required.
• Results in significantly better coverageof the breast and
significant reduction of dose to the ipsilateral lung andheart.
• Decreasesthe skin toxicity due to loss of skinfolding.
• PRONEPOSITION HASCERTAIN LIMITATIONS
 Immobilisationdevices
• Breastboard
• Wingboard
• Prone breastboard
 CARBON FIBRE
 CHEST WALLHORIZONTAL
 ARMS OUT OF BEAM PATH
 CAN USE ORFIT
 Simpler positioning device
Can be used in narrowbore
gantry
 Chest wall slope cannotbe
corrected
 IMMOBILISATIONDEVICES
• Thermoplasticshells
• Adhesivetape
• Vaclock
• Alphacradle
• Wirelessbra
• Breastring
• Breastcup
• Stocking
V
 SIMULATION
• Where available, CTsimulator hasbecome standard for planning
breastradiotherapy.
• Conventional simulator are also used
• Scar& drain sites identified with radiopaquemarkers.
• field borders are chosen & radiopaque wires areplaced
• Radiopaque wires is also placed encircling breasttissue
• CTdata are acquired superiorly from neck and
inferiorly up to diaphragm
• Slice thickness should be sufficient (usually 5mm)
 TARGETVOLUME
• AFTERBCS
– Whole breast radiotherapy +lumpectomy boost
– Regionalnodes
• AFTERMASTECTOMY
– chestwall
– mastectomyscar
– regionalnodes
CONVENTIONAL
TREATMENT
BORDERS
 TANGENTIAL FIELDBORDERS
INFERIOR
– 1-cmmargininferiorly to the inframammaryfold
SUPERIOR
– inferior edgeof the sternoclavicularjunction
Lateral
– Include all breast tissue with a1-cmmargin; this usually places this
border at the posterior to midaxillaryline.
Medial
– At the midline in most patients.3cm lateral if IMN to betreated
Anterior
– 2cmmargin of light is given abovethe highest point of the breast.
Posterior
– The deep edgesof the tangents should be coincident
 Deciding the gantryangle
• Leadwire placed on lateral border
• Field opened at 0⁰ rotation on chest wall and central
axis placed along medial border of markedfield
• Gantry rotated , until on fluoroscopy, central axis &
lead wire intersect – angle of gantry at that point is
noted– medialtangentangle
• Lateral tangential angle is 180°opposite to medial
tangent
 Things to ensure
• Ensure entire breast is covered in
portal.
• Margin of 1.5-2 cmsbeyond the
breast for respiratory excursion
• 1to 3cmof lung visible on the
simulation film in the field anterior
to the posterior field edge.
• The lead wire coincides with the
posterior edgeof the portal.
 SUPRACLAVICULAR AND AXILLARY
FIELD
• Inferior
– Determined bythe match-line with the tangential fields.
• Superior
– Radiologically, usually the superior-most portion of the first rib. it is preferable
not to clear skin(or “flash”) in the supraclavicular region.
• Lateral
– Usually medial two thirds of the humeral head. In somepatients with
extensive axillary disease, it maybe necessaryto clear skin laterally.
• Medial
– Set up to the center of the suprasternal notch (midline),then angle the gantry.
• Blocks
– lateral third of the humeral headshould beblocked
 INTERNAL MAMMARY FIELD
• Wide tangentialfield
• Direct IMN field

• Either byelectron or both photon and

electron
 DIRECTIMN FIELD
• Medial border
– Midline
• Lateralborder
– 5-6cmfrom midline
• Superiorborder
– inferior border of SCFlower border of clavicle
• Inferior border
– at xiphoid or higher if 1st three ICScovered
• Depth
– 4-5 cmor ascalculatedradiologically
Matching of fields
 POSTERIOR AXILLARY BOOST (PAB)
• Inferior:
– Block the field to matchthe superior border of the
tangentialfields.
• Superior:
– Parallel theclavicle.
• Medial:
– 2cminto the lung tissue medial to the chestwall.
• Lateral:
– At the middle of the humeral head.
 Beammodification devices used in
planning of cabreast
• Wedgefilters
• Bolus
• Tissuecompensators
 Wedgefilters
• WedgesAre UsedAs
Compensators In Breast
Radiotherapy.
• Doseuniformity within the
breast tissue canbe
improved
• Preferred in the lateral
tangential field thanthe
medial.
CONFORMALRADIOTHERAPY
Breast CTVafter BCS
Chest wall CTVafter mastectomy
Supraclavicular and axillary CTV
Internal mammarynode CTV
 Beamenergy
• X-ray energies of 4to 6MV are preferred
• Photon energies >6MV underdose superficial tissues
beneath the skin surface
• If tangential field separation is >22cm,significant dose
inhomogeneity in the breast
• Sohigher-energy photons (10 to 18MV) canbe used to
maintain the inhomogeneity throughout the entire breast
to between 93and 105%
 Dose of radiation
• Whole breast radiotherapy/chest wall irradiation
– ConventionalDose
• 50Gyin 25daily fractions given in 5 weeks
– Hypofractionated doseschedule
• 40Gyin 15daily fractions of 2.67 Gygiven in 3weeks.
• 42.5 Gyin 16daily fractions of 2.66 Gygiven in 3.5 weeks.
• Breast boost irradiation to Tumourbed
– 16Gyin 8daily fractions given in 1.5 weeks
– 10Gyin 5daily fractions given in 1 week
• Lymphnode irradiation
– 50Gyin 25daily fractions given in 5 weeks
– 40Gyin 15daily fractions of 2.67 Gygiven in 3weeks.

Palliative dose schedule- 30Gy/10#,8Gy/1#

 ROLEOF BOOST
Boost to Tumor Site after WBRTin BCS
RATIONALE:
• Localrecurrencestendto beprimarily in and around
theprimarytumor site
• boostdecreasesriskof marginalrecurrence.
• More advantageous when margins unknown &
youngwomenlessthan40yrsbut benefit seenin all
agegroup
 Localization of lumpectomycavity
Various techniques of localizing the tumour bed include:
• CTscan
• MRI
• USG
• pre opMMG
• Surgicalscar
 METHODSOFBOOST
• EBRT
– PHOTON
– ELECTRON
• BRACHYTHERAPY
– INTERSTITIAL
– INTRACAVITARY(MAMMOSITE)
 ELECTRONBOOST
• The patient is positioned with the armtoward the head to flatten
the breastcontour
• the accelerator head canpoint straight down onto the target
volume.
• An electron energy of 9to 16MeV is usually used
depending upon the depth of cavity
• The 90%prescription isodose line is limited to the chest
wall to decrease dose to thelung.
• Targetvolume is lumpectomy cavity +2cmmargin on all sides
• DOSE
– 10-20Gywith2Gy/#
The margins of this field are marked on the skin with
the centre of the scar as the centre of field
Interstitialbrachytherapy
• Anumber of needles or tubes are placed across the tumor bed
usually in 1-2 planes
• usually under general anesthetic,either using atemplate or freehand
• Needles are placed parallel and equidistance from each other
• In most casesinserted in mediolateral direction
• In very medially or laterally located tumours needles canbe inserted in
craniocaudal directionalso.
• The treatment volume is generally the tumor cavity plus a 1-to 2-cm
margin.
• The dose canbe delivered using LDRor PDRor HDR
brachytherapy,typically over 4to 5 days.
 ELECTRONBOOSTIS
PREFERED
• Relative easein setup
• Outpatientsetting
• Lowercost
• Decreasedtime demandson the physician,
• Excellent results compared with 192Ir
implants
 ACCELERATEDPARTIAL BREASTIRRADIATION
PARRIALBREASTIRRADIATION
PARTIALBREASTIRRADIATION
The target volume irradiated is only the post
lumpectomy tumor bed with 1-2cmmargin
around

ACCELERATEDDOSEDELIVERY
• The dose is delivered in ashorter interval
than the standard 5– 6weeks
• Treatments delivered twice daily (with
treatments separated bysix hours) for 10
treatments delivered in 5 treatment
days(34Gy/10#)
 RATIONALEOFAPBI
• Most breast cancer recurrences occur in the index
quadrant

• Many patients cannot comefor prolonged 5-6 week adjuvant

radiotherapy for logisticreasons

• Reducesoverall treatment period considerably

• Patient convenience mayincrease acceptance of radiation

treatment after breast-conservationsurgery
ASTROAPBI GUIDELINE
 MODALITIES OFAPBI
• HDRinterstitial brachytherapy
• Intracavitary brachytherapy:Mammosite
• 3DCRT/IMRT
• Intra-operative electrons (ELIOT)
• Orthovoltage Xrays(TARGIT)
Benefits
• Larger dose canbe delivered to small area
• Limited radiation exposure to normal tissue
• Treatments completed in one week instead of six weeks
Limitations
• May require additional surgicalprocedure
• Requires twice dailytreatment
• Newer modality with far fewer patients treated and
muchshorter follow-up
• Although the early results clearly demonstrate the
feasibility and acceptable toxicity of accelerated partial
breast irradiation, this approach hasnot yet been
demonstrated in a randomized trial to be equivalent to
whole breastirradiation.
 COMPLICATIONS OFRADIOTHERAPY
• Lymphedemaand Breast Edema
• Skin and Breast Complications
• BrachialPlexopathy
• PulmonarySequelae
• CardiacSequelae
• Contralateral Breast Cancer and Irradiation
• Incidence of Other SecondMalignancies
• Post irradiation Angiosarcomaof theBreast
 SEQUENCINGOF
RADIOTHERAPY
• Usually chemotherapy followed by
radiotherapy
• In margin +or close margin(2mm)- radiotherapy is
considered first followed by chemotherapy
• Hormon therapy to be started after
completion of radiotherapy
TRIALS PROOVING ROLEOF RTIN BCS
TRIALSPROOVING ROLEOF PMRT
 Takehome message
• RTimproves local control aswell asoverall
survival in carcinomabreast.
• RTis mandatory in post BCSpatients
• Hypofractionation in breast cancer is possible and canbe
practised
• Boost though increases local control,there is compromise
in cosmesis,so it’s adebatable issue.
• IMRT is prefered over 3DCRTANDconventional
technique.
Thankyou