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    Breast Cancer Atlas For RT Planning

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    Zuri
    The document outlines guidelines for contouring targets and organs at risk for breast cancer radiation therapy planning based on a consensus atlas developed by 10 breast radiation oncologists. It describes the variability seen between clinicians in initial contouring and improved agreement after using standardized consensus definitions. The guidelines provide anatomical boundaries for contours of the breast/chestwall, regional lymph nodes, heart and lungs to promote consistency across clinical trials and institutions.

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    Breast Cancer Atlas For RT Planning

    Uploaded by

    Zuri
    69 views26 pages
    The document outlines guidelines for contouring targets and organs at risk for breast cancer radiation therapy planning based on a consensus atlas developed by 10 breast radiation oncologists. It describes the variability seen between clinicians in initial contouring and improved agreement after using standardized consensus definitions. The guidelines provide anatomical boundaries for contours of the breast/chestwall, regional lymph nodes, heart and lungs to promote consistency across clinical trials and institutions.

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    Breast Cancer Atlas for RT Planning

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    The document outlines guidelines for contouring targets and organs at risk for breast cancer radiation therapy planning based on a consensus atlas developed by 10 breast radiation oncologists. It describes the variability seen between clinicians in initial contouring and improved agreement after using standardized consensus definitions. The guidelines provide anatomical boundaries for contours of the breast/chestwall, regional lymph nodes, heart and lungs to promote consistency across clinical trials and institutions.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    69 views26 pages

    Breast Cancer Atlas For RT Planning

    Uploaded by

    Zuri
    The document outlines guidelines for contouring targets and organs at risk for breast cancer radiation therapy planning based on a consensus atlas developed by 10 breast radiation oncologists. It describes the variability seen between clinicians in initial contouring and improved agreement after using standardized consensus definitions. The guidelines provide anatomical boundaries for contours of the breast/chestwall, regional lymph nodes, heart and lungs to promote consistency across clinical trials and institutions.

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    Treatment 

    Planning for Breast 
    Cancer: Contouring Targets
    Julia White MD
    Professor
    Outline

    1. RTOG Breast Cancer Atlas


    2. Target development on Clinical
    Trials
    Whole Breast Irradiation
    2-D Radiotherapy
    Fluoroscopic simulation Central plane dosimetry
    American College of Radiology
    Patterns of Care Study (PCS)
    Quality Research in Radiation Oncology (QRRO)

    Whole Breast Irradiation


    3-DCRT/
    Intact Central Multiple
    Breast Plane CT Scan planes IMRT APBI
    1984 98 % - - - -
    1993-94 94.1% 5% 1% - -
    1998-99 81% 16.6% 13% - -
    2007-2008 0.23% 97% 79.7% 15.8% 4.5%
    http://www.rtog.org/CoreLab/ContouringAtlases/
    BreastCancerAtlas.aspx

    Breast Cancer Atlas for Radiation


    Therapy Planning:
    Consensus Definitions

    5
    Goals: Breast Cancer Atlas
    1. Establishes initial consensus about anatomic
    delineation of target and normal tissue volumes
    for breast cancer radiation therapy
    2. Intended as an anatomical reference to guide
    CTV definition
    3. Provides a common denominator for breast
    cancer clinical trials when radiation therapy is
    to be delivered
    4. Future goals include establishment of reporting
    parameters for target and normal tissue dose-
    volumes to compare outcomes from different
    clinical trials and institutional series
    Atlas Development

    • 10 breast radiation oncologists from 9 institutions


    • Independently delineated anatomic volumes on
    three representative CT cases - twice:
    1. First: without any guidance/ instruction
    2. Second: with written consensus guidelines
    developed after the first try
    Variability of target and
    normal structure delineation
    100

    90 1
    chest wall
    2
    80 Case B 3
    70 4
    relative Volume (%)

    60 5
    heart V10: 20-45% 6
    50
    9
    40 7

    30 8

    20

    10 heart

    0
    0 1000 2000 3000 4000 5000 6000
    dose (cGy)

    Targets: lumpectomy cavity, breast, chestwall, SCL nodes, axillary nodes, IMC nodes
    OAR: heart, lung Li XA, et al, IJROPB 2009
    Comparison of the 1st and 2nd Runs

    Mean Volume Standard deviation for


    Overlapping volume variation
    1st Run 2nd Run 1st Run 2nd Run
    Breast 85% 91% 16% 10%
    Chestwall 72% 83% 38% 14%
    Heart 86% 89% 24% 15%
    Lumpectomy* 86% 90% 15% 16%
    Axillary nodes* 51% 60% 41% 40%
    Supraclav nodes 55% 58% 61% 42%

    * Not significantly different


    Case C: Stage IIIA (T2N2M0), 4/18 LN+
    Left Nodal and Breast-Chestwall RT

    First Run Second Run


    Case C: Stage IIIA (T2N2M0), 4/18 LN+
    Left Nodal and Breast RT

    First Run Second Run


    RTOG Breast Cancer Atlas
    • Geometric Average (Example)
    • Consensus Definitions
    Case B: Chestwall
    Supraclavicular
    Axillary level III
    Axillary level II
    Internal Mammary
    Heart
    Lung

    http://http://http://www.rtog.org/CoreLab/ContouringAtlases/BreastCance
    rAtlas.aspx
    Regional Nodal Contours: Anatomical Boundaries
    Cranial Caudal Anterior Posterior Lateral Medial
    Cranial: lateral
    Junction of Sternocleido edge of SCM
    Caudal to brachioceph.- Anterior aspect Excludes
    Supra- axillary vns./
    mastoid m.
    the cricoid of the scalene thyroid and
    clavicular caudal edge (SCM) Caudal:
    cartilage m. junction 1st rib- trachea
    clavicle head a muscle (m.)
    clavicle

    Axillary Pectoralis Plane defined Anterior Lateral


    vessels cross by: anterior Medial
    Axilla- lateral edge of
    (Pec.) major surface of border of
    muscle insert surface of Pec. border of lat.
    Level I Pec. Minor m. Maj. m. and subscapularis Pec. minor
    dorsi m.
    into ribs b Lat. Dorsi m. m. m.

    Axillary Lateral Medial


    Axillary vessels
    vessels cross Anterior Ribs and
    Axilla- cross lateral border of border of
    medial edge
    edge of Pec. surface Pec. intercostal
    level II of Pec. Minor Pec. Minor Pec. Minor
    Minor m.
    c Minor m. muscles
    m. m. m.

    Axillary vessels Medial


    Pec. Minor Posterior Ribs and
    Axilla- cross medial border of Thoracic
    m. insert on edge of Pec.
    surface Pec. intercostal
    level III Pec. Minor inlet
    cricoid Minor m. d. Major m. muscles
    m.

    Internal Superior
    Cranial aspect
    aspect of the - e. - e. - e. - e.
    mammary medial 1st rib. of the 4th rib
    Breast/ Chestwall Contour: Anatomical Boundaries

    Cranial Caudal Anterior Posterior Lateral Medial


    Clinical
    Clinical Clinical Excludes Reference +
    Reference reference + pectoralis mid axillary Sternal-
    Breast + Second loss of CT Skin muscles, line typically, rib
    rib apparent chestwall excludes junction c
    insertiona breast muscles, ribs lattismus (Lat.)
    dorsi m. b
    Includes
    Breast- pectoralis
    Same Same Same mucles, Same Same
    Chestwall2\ chestwall
    muscles, ribs

    Clincial Rib-pleural Clinical


    Caudal interface. Reference/
    reference+
    border of (Includes mid axillary Sternal-
    loss of CT
    Chestwall3 the Skin pectoralis line typically, rib
    apparent
    clavicle mucles, excludes junction b
    contralateral chestwall lattismus dorsi
    head
    breast muscles, ribs) ma
    Nanoparticle-enhanced MRI To Evaluate Regional
    Lymphatics For Patients With Breast Cancer

    • MGH: 23 patients
    • LN-MRI: Lymphotrophic
    nanoparticle–enhanced MRI to
    identify benign versus
    malignant lymph nodes

     No consistent relationship
    between malignant and/or
    benign lymph nodes and bony
    and/or vascular anatomy was
    determined.
    Red nodes: Metastatic
    MacDonald et al, IJROBP 77:2010 Green nodes: Benign
    Nanoparticle-enhanced MRI To Evaluate Regional
    Lymphatics concordance with RTOG Contouring ATLAS
    • Lymph node regions were contoured on CT according to RTOG
    guidelines
    • % LN-MRI lymph nodes contained within these contours
    determined
    • 86% of actual lymph nodes and 89% of sampled lymph nodes
    were within contoured RTOG consistent nodal volumes
    • 99% of actual and sampled lymph nodes were included when a
    5-mm expansion was added.

    MacDonald et al, IJROBP 77:2010


    Contour Development and Clinical Trials
    Year Targets Clinical Trial
    2003 • Lump CTV - RTOG 0319
    2005 • Lump PTV - NSABP B39/RTOG 0413
    • Lump PTV_eval

    2010 • Breast CTV - RTOG 1005


    • Breast PTV
    • Breast PTV_eval

    2013 • Chestwall CTV -NSABP B51/ RTOG 1304


    • Chestwall PTV - ALLIANCE A011202
    • Chestwall PTV_eval
    • Axilla CTV
    • Axilla PTV
    • IMN CTV
    • IMN PTV
    • SCL CTV
    • SCL PTV
    NSABP B-39/RTOG 0413 Trial
    Phase III

    Stage 0, I-II breast cancer treated by lumpectomy

    Randomization
    APBI
    WBI • 34 Gy in 3.4 Gy fxs bid
    Mammosite® , Contura, SAVI or
    • 50-50.4 Gy (1.8-2.0 Gy)
    Multicatheter brachytherapy
    Fractions to the whole breast
    OR
    followed by boost to 60 -66.6 Gy
    • 38.5 Gy in 3.85 Gy fxs bid
    3D-CRT

    March 2005- April 2013 accrual = 4,216


    NSABP B-39/RTOG 0413
    Defined Lumpectomy Targets and
    Dose Volume Constraints for APBI

    1.5 cm expansion
    1 cm expansion around CTV
    around surgical cavity
    STRATIFICATION:

    RTOG 1005 Age: < 50 vs > 50


    Chemo: yes vs no
    ER: + vs. -
    Phase III
    “High risk” Stage 0, I-II, breast cancer treated by lumpectomy

    Randomization

    Standard WBI- Hypofractionated WBI-


    Sequential boost Concomitant boost
    • WBI: 50 Gy (2.0 Gy)
    • WB PTV: 40 Gy/ 2.7 Gy
    42.56 Gy (2.67 Gy)
    •Lumpectomy PTV: 48 Gy/ 3.2 Gy
    • Boost: 12-14 Gy ( 2 Gy)
    15 Fractions
    22-33 Fractions
    3 weeks
    4.5-6.5 weeks
    Targeted accrual = 2312
    Opened May 2011
    RTOG 1005: Defined Breast Targets
    and Dose Volume Constraints
    NSABP B-51/RTOG 1304 Trial Phase III
    - Clinical T1-3N1M0 breast cancer
    - Pathology positive axillary node (FNA/Core)
    - Neoadjuvant CT + anti HER2
    ypN0 at definitive Breast Surgery + AND or SNB

    Randomization

    Arm 1 Arm 2
    No Regional Nodal XRT Regional Nodal XRT
    A. Lumpectomy: Breast XRT. A. Lump.: Breast/Nodal XRT
    B. Mastectomy: Observation B. Mast: Chestwall/ Nodal XRT
    Targeted accrual = 1636
    Opens8-2013
    Stratification: Type of Surgery (Mast v. Lump) , ER-Status (+ v. –), HER2
    Status (+ v. –), pCR in Breast (yes v. no)
    Alliance A011202 Trial (select): Phase III
    - Clinical T1-3N1M0 breast cancer
    - Pathology positive axillary node (FNA/Core)
    - Neoadjuvant CT + anti HER2
    - Surgery with sentinel lymph node biopsy

    Positive Sentinel LN Identified

    Intra OP Reg + Randomization

    Arm 1 Arm 2

    ALND + Nodal XRT No ALND + Nodal XRT


    Targeted accrual = 1576
    NSABP B-51/RTOG 1304
    Defines Chest Wall And Regional
    Nodal Targets and Dose Volume
    Constraints
    NSABP B-51/RTOG 1304: Contouring Appendix
    Thank you!

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