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Radiation Oncology

Radiation Oncology. Demystified. Patient Populations We Treat. Early Breast Cancer (incl. DCIS): post-lumpectomy Locally Advanced Breast Cancer: post-Mastectomy Recurrent Breast Cancer: chest wall nodules Metastatic Breast Cancer: bone mets , brain mets Not LCIS

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Radiation Oncology

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  1. Radiation Oncology Demystified

  2. Patient Populations We Treat • Early Breast Cancer (incl. DCIS): post-lumpectomy • Locally Advanced Breast Cancer: post-Mastectomy • Recurrent Breast Cancer: chest wall nodules • Metastatic Breast Cancer: bone mets, brain mets • Not LCIS • Not DCIS if s/p Mastectomy

  3. Think Twice • Connective Tissue Disorder, esp. Scleroderma • Really young • Really old • Previous Radiation Therapy to same site • History of Radiation Induced Malignancies

  4. Special Cases • Reconstruction • Bilateral (Ca and/or Reconstruction) • Comorbidities (such as diabetes, CTDs, CVD, asthma, lymphedema, port, genetic predisposition to malig) • Tight Arm after Axillary Lymph Node Dissection • Previous Radiation Therapy Tx, or Rad Exposures • On systemic treatments that may affect healing or scarring (antiangiogenic; taxoxifen) • On herbals and/or high dose vitamins

  5. Targets • Breast • Chest Wall • Supraclavicular/Axillary Apex • Partial Breast • Operative Bed • Recurrent Chest Wall Nodules • Bone Mets • Brain Mets

  6. Beams • Photons • Electrons (boost, intraop) • Orthovoltage (TARGIT) • Additional Devices • Bolus • Tattoos • Custom Bra • Hyperthermia • Port films

  7. Skin Care • Moisturizers • Antifungal/Antinflammatory • Astringent Soaks • Mepilex • Mesh “Bra” • Avoid Underwire • Moisturize Irradiated Skin Forever! • Follow Up

  8. Simulation

  9. CT-based Treatment Planning

  10. E- Beams

  11. Photon Beams: Single 6 or 18 MV cobalt

  12. Photon Beams: Parallel Opposed

  13. Photon Beams: 6 vs. 18 MV parallel opposed

  14. Tangents

  15. 65 cGy 15 cGy 10 cGy = 90 cGy + + Dose Cloud Technique (IMRT) Successive Cone Downs on Medial and Lateral Tangential Fields, For example: Medial Field 1 Medial Field 2 Medial Field 3 Heart Block Dynamic Leaves Computerized

  16. CT based Treatment Planning

  17. What might the plan look like if we treated the internal mammary nodes? Direct AP Photon Field For IMC Too Much Heart Hockey-stick OLD DAYS

  18. What might the plan look like if we treated the internal mammary nodes? Co-60 e- 50% e- 10 % e- 0 % e- 50% Co-60 10 % Co-60

  19. What might the plan look like if we treated the low internal mammary nodes with tangential fields? 3cm

  20. So what is our target? After BCS • Traditionally • Whole breast +/- boost to operative bed & scar • Most agree • At least: Operative bed + 1 cm • Some would say • Operative bed + 2-3-4 cm • Whole breast • Chest wall

  21. Histologic evidence of tumor in IMC Extended Radical Mastectomy A u t ho r P a t ie n t s O u t e r Q ua d ra n t I n n e r Q u ad r an t A ny Q u ad r an t U r b an 53 % 341 42 % B u ca l ossi 553 29 % Ha n dl e y 48 % 535 21 % L i 35% 635 25 % As high as 53%

  22. What about after Mastectomy? Patterns of Locoregional Failure Clavicular Internal Mammary Axilla No. of Patients Chest Wall Univ. Hospital of Cleveland* 209 59% 25% NS 7% M. D. Anderson* 148 60% 13% 3% 7% Malinckrodt 129 33% 11% 18% 77% 83% Univ. of Pennsylvania 128 25% 3% 11% Institute Jules Bordet 128 77% 25% NS 10% Mt. Sinai - Miami 124 77% 11% 8% 21% ECOG * 70 53% 24% NS 11% DBCG 214 64% 17% NS 34% 53 - 83% 0 – 11% *Details about multiple sites not provided

  23. Risks: IMC Failure • An IMC failure is difficult to salvage. • Reirradiation of this area would be morbid. • There is no proven survival advantage to treating the IMC region • In select patients we do treat the upper IMC region • Luckily, it is clear that the IMC region can be safely excluded for patients with DCIS, so we can even better spare the heart and lung in those patients.

  24. Risks: Local Recurrence • Some patients who wished for breast conservation will require a mastectomy. • Reirradiation can cause tissue and chest wall necrosis and severe fibrosis. We treat with 400 cGyx 8 with hyperthermia. • Without reirradiation, the salvage surgery will need to be a larger procedure (wide margins) and the patient may yet fail again. • It’s not a pretty picture.

  25. Chest Wall Failure • This is not where we want to be. • This is not salvagable.

  26. Important Questions . . . Pandora’s Box • Physician philosophy on IMN treatment • Risks • Benefits • Physician philosophy on partial breast irradiation • Will leave some breast out of field to spare heart? • Use of mammosite or other brachytherapy device? • Physician philosophy on margin status • Caveat: No national consensus on above, and the actual treatment plan greatly depends on • the patient’s anatomy in treatment position • institutional standard of care • Clinical judgment • informed patient choice

  27. TARGIT

  28. Hyperthermia

  29. Mammosite

  30. IMRT Breast

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