APBI Journal Club PowerPoint

APBI: Accelerated

Partial Breast
Irradiation
PRESENTED BY REGAN HIME
Overview
 What is APBI?
 Why APBI?
 APBI Phase III clinical trial results
 What are the optimal candidate characteristics for APBI?
 Treatment planning considerations
CT
Beam Arrangement
Setup imaging
Plan checks

 Treatment setup considerations

IGRT
SGRT
 Summary
 I will be happy to take any questions at the end of the presentation
What is APBI?
 Current gold standard for women with early-stage breast cancer is breast conservation therapy
in which the patient gets a lumpectomy and then receives whole breast irradiation (WBI).
 APBI is an alternative to WBI, defined as “radiation of the site of excision and adjacent breast
tissue only…that uses fractions >1.8–2.0 Gy/d within <5–6 weeks”1.
 Can be done through a variety of modalities including interstitial brachytherapy,
brachytherapy using balloon catheters, and external beam radiation therapy.
Interstitial Brachytherapy Brachytherapy using balloon catheters External Beam Radiation Therapy
Why APBI?
 Breast cancer is the second most common non-skin cancer and 5th leading cause of death by
cancer.
 Every one in eight women in the U.S. will be diagnosed with breast cancer.
 Shorter courses predict women are more likely to follow through with treatment.
 Accelerated treatment on a whole breast would cause unacceptable normal tissue toxicity.
 Recurrence usually occurs local to the original disease.
 In addition, APBI allows for cosmesis, organ sparing, and fewer later effects compared with
WBI.
Outcomes from Clinical Trials
 One of the early Phase III clinical trials focused on 3D-CRT and excluded IMRT treatment
techniques for a total of 60 patients.
 This trial used a dose fractionation scheme of a total dose of 38.5 Gy, 3.85 Gy/fraction at two
fractions a day >6 hrs apart to total 10 fractions in 5 days of treatment.
The study followed the NSABP/RTOP protocol for Phase III clinical trials.
 The clinical trial’s results are summarized as follows:
 At a median 15 month follow, 10% of patients developed moderate to severe late toxicity
 25% of patients developed moderate-to-severe late subcutaneous fibrosis
 25% of patients developed clinical evidence of fat necrosis
 Cosmetic outcome was good to excellent in 81.7%, fair in 11.7%, and poor in 6.7% of patients
Outcomes from Clinical Trials
 A more recent Phase III clinical trial compared APBI via IMRT treatment delivery with
conventional WBI for a total of 520 patients.
 This study used a dose fractionation scheme of a total dose of 30 Gy, 6 Gy per fraction for a
total of 5 fractions delivered every other day
 At a 10 year follow-up, the clinical trial’s results are summarized as follows:
 No significant differences in Breast Cancer Specific Survival and Overall Survival between APBI and WBI
No significant differences in number of patients with second primary cancers
APBI resulted in significantly improved treatment-related acute and late adverse events
No significant difference in ipsilateral breast tumor recurrence
 APBI cosmesis results were superior to WBI
Optimal Candidates
for APBI
 ASTRO Task Force for APBI categorizes patients as suitable, cautionary, or unsuitable APBI
candidates.
 Candidates falling in the suitable category have the following characteristics:
 Over the age of 50
 T1 primary cancers
 20 mm or less at the widest part of the tumor
 Negative nodes
 Positive estrogen receptor status
 Absence of lymphovascular space invasion
 Widely negative margins
 No multicentricity
CT-Sim
 At CT-sim, ideal setup is arms up, using Vac-Lok
 No breast board because of clearance issues
 The CT should start at or above the mandible and extend several cm below the inframammary
fold (including the entire lung).
 4D Chest or Chest protocol is used (0.2 cm slice thickness)
 4D untagged images can be used for physician to evaluation Maximum Intensity Projection
(MIP) of tumor while drawing volume (physician preference).
 If 4D scan is taken, free breathing scan is used for treatment planning, due to 4D scan
sometimes coming out grainy.
Contouring
Target
and OARs
 Physician draws Op Bed based on images, clips, and scar
wire.
There are two ways to determine CTV and PTV from Op Bed:
1. CTV is a 1.5 cm margin around Op Bed, then bone lung, etc. are
removed to get final CTV. PTV is then 0.5 cm margin around
CTV.
2. CTV is a 1.0 cm margin around Op Bed, then bone lung, etc. are
remove to get final CTV. PTV is then 1.0 cm margin around CTV.
 Dosimetrist contours each breast separately, clips, heart,

each lung separately, and scar wire
 Breast with op bed is contoured as the breast volume minus the
PTV volume
 PTV is pulled back 3 to 5 mm from skin per physician preference
Contouring Target and OARs
Beam Arrangement
 Treatment types can include 3D-CRT, IMRT, and VMAT.
 At CARTI, the treatment team has employed both IMRT and VMAT treatment planning.
 Deep Inspiration breath hold (DIBH) not applicable.
 VMAT beam arrangement consists of two arcs. These arcs vary depending on the patient.
 If dosimetric constraints cannot be met, IMRT may be necessary.
 IMRT beam arrangements can vary depending on location of PTV.
 Couch kicks can be added if necessary.
Beam Arrangement Examples
IMRT VMAT
On each side, start at about normal tangent, 20° 200° CW 50°
spacing between 3 beams 50° CCW 200°
Constraints
 Typical prescription is
600 cGy x 5 fractions
every other day
Physics Checks
 Contours are reviewed.
Dose constraints are reviewed.
Beam arrangement is reviewed.
 Plan undergoes physics QA measurement.

Patient Setup:
SGRT
 For patients at locations where surface guided
radiation therapy (SGRT) is available, this technology is
utilized for patient setup.
 Although it does not replace daily imaging, it can help
with reducing setup time, as well as aiding in
repositioning the patient when necessary which can
help correct the position of the breast to align better
with the desired setup.
 Can be used for patient monitoring during treatment.
Patient Setup: IGRT
 The imaging order is CBCT daily to the target (soft tissue)
 Surgical clips can also be used as a surrogate to help with target localization
 Studies have shown CBCT imaging to the target using surgical clips can significantly reduce
target localization error compared with bony registration or breast surface registration in most
cases.
 Doctor comes to approve image shifts at console every day.
Patient Setup
Summary
 APBI is a good alternative to WBI after a lumpectomy for patients that are considered suitable
candidates.
 APBI versus is WBI is a more convenient and cost effective treatment option.
 Cosmesis and late affects are improved with APBI versus WBI with no significant difference in
cancer recurrence.
 APBI is a new treatment option at CARTI. The process is not yet fully standardized.
References
1. Toxicity of Three-Dimensional Conformal Radiotherapy for Accelerated Partial Breast Irradiation
2. Accelerated Partial Breast Irradiation: Caution and Concern from an Astro Task Force
3. Accelerated Partial Breast Irradiation (APBI): A Review Of Available Techniques
4. RTOG 0413: A Randomized Phase III Study of Conventional Whole Breast Irradiation (WBI) Versus Partial
Breast Irradiation (PBI) for Women with Stage 0, I, or II Breast Cancer
5. Image Guidance In External Beam Accelerated Partial Breast Irradiation: Comparison Of Surrogates For
The Lumpectomy Cavity
6. Recent Advances In Surface Guided Radiation Therapy
7. Accelerated Partial-breast Irradiation Compared With Whole-breast Irradiation For Early Breast Cancer:
Long-term Results Of The Randomized Phase III APBI-IMRT-Florence Trial
8. Personal Communication with CARTI Staff
THANK YOU!
ANY QUESTIONS?

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APBI: Accelerated

 Treatment setup considerations

 Dosimetrist contours each breast separately, clips, heart,

 Plan undergoes physics QA measurement.

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