Rachel A . Hacket t CMD, RTT
PRONE BREAST –WHAT’S THE BIG DEAL?
Surgical Options For the breast:
Breast conserving surgery (lumpectomy) Breast Conservation
Therapy = surgery + radiation Mastectomy +/- immediate
reconstruction For lymph node
assessment: Sentinel lymph node biopsy Axillary lymph node
dissection
BREAST CANCER TREATMENT OPTIONS
Systemic therapy options: Chemotherapy Can be given either before or after surgery Neoadjuvant or adjuvant Selection for use depends on stage and extent of disease, type of breast cancer and
features (ER , PR, Her2 status), potential for down-staging to breast conservation, assessment of response
Endocrine therapy / hormonal therapy Examples: tamoxifen, aromatase inhibitors, ovarian suppression
BREAST CANCER TREATMENT OPTIONS
Role of radiation in the setting of breast conservation and post mastectomy:
Improvement in local or locoregionalcontrol
Survival benefit in invasive carcinomas and in the post mastectomy setting Disease free survival Overall survival
RATIONALE FOR RADIATION
TARGETSWhole breastPartial BreastChest wallRegional nodes
RADIATION TREATMENT OPTIONS
DOSE and FRACTIONATION Conventional Fractionation 1.8-2 Gy per fraction to total dose 45-50.4 Gy
Hypofractionation Shorter course utilizing larger doses per fraction >2 Gy per fraction to lower total dose 40.05 – 42.56 Gy given in daily fxs for whole breast 34-38.5 Gy given twice daily fxs for partial breast
Accelerated course Treatment over shorter time course
RADIATION TREATMENT OPTIONS
MODALITIES:External Beam Photons Electrons Protons
Brachytherapy Radioactive source Device
Intraoperative Various means
RADIATION TREATMENT OPTIONS
TECHNIQUES: Positioning Supine vs Prone
CT simulation and volume based planning 3D conformal, e comp, IMRT Respiratory control with deep inspiration breath hold technique “respiratory gating”
RADIATION TREATMENT OPTIONS
How is treatment tailored to the individual patient?
Patient factors Treatment factors Disease burden Biology Risks for disease morbidity vs treatment morbidity
RADIATION TREATMENT OPTIONS
Patient factors: age, comorbidities Treatment factors: type and extent of surgery, type of
systemic therapy, response to neoadjuvant therapy Disease burden: T stage / size, N stage / # / ratio, ECE,
LVSI, EIC, margins Biology: grade, ER, PR, Her2, gene profile
RADIATION TREATMENT OPTIONS
POSITIONING OPTIONS:
Respiratory gating cube and glasses
Prone breast board
USE OF “RESPIRATORY GATING”
Free Breathing
Breath Hold
RATIONALE FOR PRONE POSITIONING
Prone position used for stereotactic core biopsy and breast MRI
Technique adopted and modified for radiation treatment delivery
Displacement of breast tissue away from chest wall and torso
Minimize acute and late skin effects Minimize skin folds Particularly in women in large pendulous breasts High BMI/obesity
Minimize dose to normal tissues Lung Heart Medical co-morbidities: underlying pulmonary disease
(COPD, smoker), cardiac disease, collagen vascular disease, prior RT
RATIONALE FOR PRONE POSITIONING
Select patients with early stage disease
Breast is target
Minimize normal tissue doses and treatment toxicity
USE OF PRONE POSITIONING
MSKCC, USC, NYU, MCW, OSU, and others
Whole breast Partial breast Concomitant boost Ongoing investigations for nodal regions, extended fields
Lower lung doses Often lower heart doses Less skin toxicity No increased recurrences Reproducibil ity
EARLY EXPERIENCES WITH PRONE
Thoughts on implementing prone positioning
Important to have as an option for breast cancer treatment to minimize toxicity
TEAM approach
Requires active physician involvement and engagement throughout care (clinic, simulation, planning, verification, treatment)
Learning curve
THOUGHTS ON PRONE POSITIONING
Definitions: Breast contour: Clinical breast tissue Includes lumpectomy CTV Excludes pectoralis muscles,
chest wall, ribs Chest wall contour: From skin to rib/pleural
interface Includes pectoralis muscles,
chest wall, ribs Breast + chest wall: For more locally advanced
/ high risk patients Regional nodal volumes
RTOG CONTOURING ATLAS
White et al, RTOG Breast Cancer Contouring
BREAST CONTOUR
REGIONAL NODAL VOLUMES CONTOURS
Other considerations: CTV Location Inner quadrants, particularly upper inner, can be challenging Anterior/skin extent Posterior extent of disease and proximity to chest wall/pectoralis
muscles
Select patients with early stage disease
Breast is target
Minimize normal tissue doses and treatment toxicity
PATIENT SELECTION FOR PRONE
Early stage diseaseStage 0, I, II
Following breast conserving surgery
Target = breast tissue not chest wall not lymph nodes not post-mastectomy
PATIENT SELECTION FOR PRONE
LIMITED NODAL COVERAGE WITH TANGENTS IN PRONE POSITION
Csenka et al, Therapeutics and Clinical Risk Management 2014
LIMITED NODAL COVERAGE WITH TANGENTS IN PRONE POSITION
Leonard et al, Radiation Oncology 2012
REVIEW OF BREAST MRI CAN BE HELPFUL
Need to be able to get into the prone position and maintain stable position Arm and neck range of motion Back pain Agility and flexibility Body habitus Respiratory status Performance status Asking the patient about she tolerated prior biopsy procedure and /
or MRI can be helpful
PATIENT SELECTION FOR PRONE
Physician presence to check set up wires, marks, positioning and reproducibility, anticipated tangent fields and heart and lung dose
ASSESSMENT AT SIMULATION
OPTIONS TO MINIMIZE CARDIAC DOSE
Beck et al, Frontiers in Oncology 2014
POSITIONING AND HEART LOCATION
Huppert et al, Frontiers in Oncology 2011
ClearVue Prone Breast Board Indexed to CT-Sim
couch and Linaccouch Interchangeable for
right and left breasts
CT-SIM SETUP
Inser t Opt ions and Dimensions
CT-SIM SETUP
Limited to 18cm of space between surface and base
Rulers Vertical Horizontal
CT-SIM SETUP
Step stoolPatient push-ups Sheet sizePillow casesKeep horizontal ruler
set
CT-SIM SETUP
WiresLumpectomy scarNodal scarMidlineEdge of both breast
tissueBorders of breast
tissue (2 cm margin)
CT-SIM SETUP
Head turned toward ipsilateral side Creates a tripod
position(minimize rotation) Body NOT rotated into
opening Arms above head holding
bars Knee roll cushion under
ankles Patient moves so ML wire is
palpable and visible in cutout opening
Swipe contralateral breast out
Keep couch lateral at 0
CT-SIM SETUP
Table is as low as possible Includes entire body
contour
SUP/INF position of breast centered in cutoutCT angle of
mandible to L3
CT-SIM SETUP
CT-SIM SETUP
5 Tattoos 1 on breast Mid nipple Relatively flat
4 on back Lower straightening about 15-20cm inf the upper
tattoo Avoid pants
Laser at 0 Not necessarily midline
Landmarks Most inf crease of neck Record rulers Vertical Horizontal
CT-SIM SETUP
Breast tattooToo small not enough surface area
Too irregular No stable area to place
tattoo
May have to put tattoo more posterior
SETUP CHALLENGES
Breast hang is more than 18cmUse styrofoamBreast “puddles” on
styrofoam
SETUP UP CHALLENGES
Moving patients on the prone board Transfer sheets
Patients rolling into cutout
Neck pain Use cushion under head Patient movement to
readjust Tried using warm rice
bags
SETUP CHALLENGES
Wire contralateral breast with double solder wire Documents edge of
treatment field
Image all fieldsDaily PF for 1st
week of treatment
VERIFICATION DAY
TREATMENT SETUP
TREATMENT SETUP
Set table Couch lateral to zero Set horizontal ruler
Patient moves into settings
Swipe contralateral breast
TriangulateFeel for sternumBar pushed in so not
treated through
TREATMENT SETUP
Table raised to breast tattooGantry rotated to
lateral referenceSet SSD on breast
tattooRotate gantry to
lateral treatment field check treatment SSD
TREATMENT SETUP
BBS + USER ORIGIN
DAILY TX ISO SHIFT
TX FIELDS
TX FIELDS ON SKIN
TREATMENT FIELDS
NORM POINT AND DOSE
ORTHOGS
ORTHOGS
MOSAIQ
Dosimetric Comparison of 3D-CRT, ECOMP, and Hybrid IMRT Plans for Prone Whole Breast Irradiation
Haley Lowe, BA, Rachel Hackett C.M.D., Ir is Wang Ph.D, Kil ian Salerno M.D.R o s w e l l P a r k C a n c e r I n s t i t u te | B u f f a l o , N e w Y o r k
3D-CRT, ECOMP, AND HYBRID IMRT
• 20 patients post breast conservation surgery simulated in the prone position on a specialized prone breast board (10 right sided, 10 left sided)
• Dose prescription: 40 Gy in 15 fractions
• 3 treatment plans per patient were designed using Varian Eclipse 11 to treat the whole breast to the 95% isodose line
• Plans were tradit ional 3D-CRT plan using wedges, ECOMP plan, and Hybrid IMRT—where 2/3 of the dai ly dose is del ivered with 3D-CRT and remaining 1/3 dose with forward planned IMRT
• Use of prone posit ion for whole breast radiotherapy may achieve a significant reduction in lung and heart radiation dose when compared to tradit ional treatment in the supine posit ion.
• Treatment del ivery with ECOMP or a hybrid IMRT technique can fur ther reduce heart and lung dose compared to 3D-CRT with wedges.
• Hybrid IMRT provides a significant reduction in maximum breast dose.
• ECOMP al lows for the maximum decreases in mean heart dose while maintaining a relatively low maximum dose.
3D-CRT, ECOMP, AND HYBRID IMRT
3D-CRT, ECOMP, AND HYBRID IMRT
Evaluation and dosimetric comparison of V20, heart dose and maximum dose for dif ferent prone whole breast irradiation planning techniques including 3D-CRT, ECOMP and hybrid IMRT.
3D-CRT, ECOMP, AND HYBRID IMRT
• Global maximum dose for al l patients was reduced while maintaining dose homogeneity using both ECOMP and hybrid IMRT when compared to 3D-CRT. Maximum dose reduction using hybrid IMRT averaged a 1 .3 Gy dose reduction compared to 3D-CRT planning.
• No dif ference in ipsi lateral lung V20 was seen between the dif ferent planning techniques.
• Mean heart dose was reduced in the ECOMP and hybrid IMRT plans compared to the 3D-CRT plans. Hybrid IMRT reduced mean heart dose by 0.7 Gyfor the right breast, 0.9 Gyfor the lef t; ECOMP reduced mean heart dose by 2.2 Gyfor the right, and 2.9 Gy for the lef t.
• There was no correlation found between the breast volume and maximum dose, ipsi lateral lung V20, or mean heart dose.
3D-CRT, ECOMP, AND HYBRID IMRT
IRREGULAR SURFACE COMPENSATORS
IRREGULAR SURFACE COMPENSATORS
IRREGULAR SURFACE COMPENSATORS
INHOMOGENEITY CORRECTION ON: OPT + CALC
EDIT FLUENCE - MAKE IT FLASHY
RESULT OF DOSE CALCULATION
LACK OF TANGENTIAL DOSE
PRESCRIBE DOWN –“PAINT” OUT THE HOT
HEART DOSE
HEART AVOIDANCE
LUNG DOSE REDUCED – A LOT
LUNG DOSE REDUCED – A LOT
Kilian Salerno, MD Simon Fung-Kee-Fung, MD Maria Durlak, RTT
THANK YOU!