EARLY BREAST CANCER(EBC)

DR.VIJAYAVEERAN.P MD(RT)
IONIZING RADIATION

 Ionization is the process in which the radiation results in

ejection of one or more orbital electrons from the atom
or molecule
 Large amounts of energy released at ionization
 Breakage of strong chemical bonds
 Initiation of a chain of events
 Culminate in a biological change
 MOA - RT

Free radicals
produced in a
cylinder with a
diameter double that
of the DNA helix can
affect the DNA

The fast electrons

may interact directly
with the DNA in the
cells
DOUBLE-STRAND BREAK

 Breaks may be opposite to each other or separated

by only a few base pairs (The piece of chromatin
snaps into two pieces)
 RADIATION EMPLOYED IN RT

Electromagnetic Particulate radiations

radiations
Electrons
X-rays
Neutrons
-rays
Protons
Negative -mesons
Heavy charged
ions
 RADIOTHERAPY MACHINE
 Tele therapy
Type of radiotherapy when the external source of radiation is many
centimeters from the part being treated

 Brachytherapy
Form of radiotherapy where the source of radiation is kept very close
to the tissues being treated or is actually implanted into the tissues

 Internal therapy
Treatment by radioactive isotopes incorporated into body tissues
 TELE THERAPY
X-RAY : Linear Accelerator (LINAC)
GAMMA RAY : Co 60 Machine

BRACHYTHERAPY
 Ir -192 brachytherapy
Co-60 brachytherapy
 BCS vs BCS + RT

 BCS alone showed a 3 fold increased risk of local

recurrence in the breast.

 8.6 % excess mortality without addition of radiation.

 Radiation sterilizes the probable micro metastasis left

behind after surgery.
 RCTs COMPARING BCS +RT vs MRM

MILAN NSABP 06 EORTC

No of pts 701 1219 874

Stage 1 1,2 1,2

Surgery Quadrentectomy Lumpectomy 1 cm gross

margin
Follow up yr 20 20 10
BCS+RT OS 42 46 65

MRM OS 41 47 66

BCS+RT LR 9 14 20

MRM LR 2 10 12
RADIATION DOSE AND FRACTIONATION

Whole breast dose 45-50 Gy/ 20-25 #

Boost to tumor bed 10-15 Gy/ 5-8 # electron

beam therapy.

EORTC Boost trial showed an improvement in

local control with the use of boost (4.3% with
boost v/s 7.6% with no boost).
 POST BCS RADIATION

2D(2 Dimensional) Photon + Electron

3D CRT
IMRT
TANGENTIAL FIELDS-2D Tech

Tangential fields  Medial: At or 1cm

beyond midline (if no IM
portal is used)
 Upper: At head of
clavicle
 Lateral: 2 cm beyond all
palpable breast tissue
near midaxillary line
 Inferior: 2-3 cm below
inframammary fold
TBB ELECTRON -2D Tech

 Post lumpectomy volume on the

scar on the skin + 2-3 cm in all
directions
 Target volume definition is critical
with any boost technique –USG &
CT definition of target volume,
metallic surgical clips
 Energy of electrons 12 or 16 MeV
 3D CRT- Tech
Reduction in
volume of normal
tissues receiving
high dose with an
increase in dose to
target volume that
includes the tumor
& limited amount of
normal tissue
 IMRT-Tech

Further improves dose distribution between

target & non-target tissues
ACCELERATED PARTIAL BREAST IRRADIATION(APBI)

RATIONALE
 Technique to deliver RT post breast conservation surgery in early
breast Ca.
 Usually RT is delivered to the whole breast + tumour bed boost.
 APBI – Treat a smaller volume with high dose in short period of time.

 NSABP B-06 trial confirmed that the pattern of local recurrence was at,
or near, the lumpectomy site in 75% of the recurrences
 An additional theoretical advantage of APBI is a decreased dose to
normal tissue.
APBI-Tech

1. Multi catheter interstitial implants,

2. Mammo-site (balloon catheter),
3. Hybrid Brachytherapy Devices,
4. External beam 3D conformal partial breast radiation,
5. Intraoperative single dose irradiation.
MULTI CATHETER INTERSTITIAL IMPLANTS

 Flexible after-loading catheters are placed through the breast

tissues surrounding the lumpectomy site during surgery.
 The catheters are inserted at 1 to 1.5 cm intervals in several
planes, to ensure adequate coverage of the lumpectomy
cavity plus margins , and to avoid hot and cold spots.
 The exact number of catheters and plane being determined
by the size, extent and shape of the target.
 Dose – 3.4Gy per fraction, twice daily for 5 days. TD – 34 Gy.
MAMMO-SITE

 It is a silicone balloon connected to a double-lumen catheter.

 One lumen is to inflate the balloon and the other central lumen is for
the Ir-192 source to pass through.
 The balloon is inflated with saline solution mixed with a small amount
of contrast material to aid visualization.
 The balloon is inflated to a size that would completely fill the
lumpectomy cavity and ensures complete coverage of the target.
 Dose – 3.4Gy per fraction, twice daily for 5 days. TD – 34 Gy.
 This dose is prescribed to a point 1 cm from the surface of the
balloon.
MAMMO-SITE
HYBRID BRACHYTHERAPY DEVICES
 Axxent Electronic Brachytherapy
Electronic 50 kilo-voltage x-ray source, three
channels.
The balloon is covered in radiolucent material
that is visible on a plain x-ray film or CT scan
 Contura
The Contura balloon has four surrounding
channels,
The source passes through two channels to get
an adequate coverage.
INTRA-OPERATIVE RADIATION THERAPY (IORT)

 Single dose of irradiation is delivered directly to the tumour

bed during surgery.

 Rationale
i) Delivering radiation before tumour cells proliferation.
ii) Surgical bed has rich vascularity (O2 potentiates effect RT)
iii) Direct visualization of bed. (Imaging not required)
iv) Skin sparring – Skin can be displaced from the field of RT.
Perspex applicator and aluminium-lead disc
INTRABEAM (X-RAYS)
External Beam Radiation Therapy (3DCRT)
 Non invasive method to deliver APBI
 The tumour bed is defined by the seroma,
postoperative changes, and surgical clips as
visualized by CT scan.
 Clinical target volume (CTV) is defined as the tumour
bed with a 1.5 cm margin, 0.5 cm away from the skin
and chest wall.
 Planning tumour volume (PTV) is defined as the CTV +
1.0 cm margin.
 Dose used for NSABP/RTOG protocol is 3.85 Gy twice
daily to a total dose of 38.5 Gy delivered over 5 days.
 APBI
Inclusion: Exclusion:
• Postmenopausal • Young patients
• T2 or less • Large tumors
• N0 • N+
• High grade
• Low grade
• Multi centric
• Negative surgical
margins • Invasive lobular
histology
• ER +
• Positive surgical
margins
CONCLUSIONS
RT improves local control and survival
Evidence of better local control with RT
Boost
APBI may be an alternative to WBRT –
investigational
Smaller treatment volume & time
Dose intensity
Decreased toxicity
Increased acceptability (patient / physician)
APBI requires
Optimal patient selection
Appropriate target delineation
Meticulous QA
Can RT be avoided following BCS
 NCCN guidelines allows BCS + hormones without
breast radiation in women
 70yrs of age
 Clinically negative nodes
 ER positive
 T1 tumor with negative margins

No difference in OS,DFS or need for

mastectomy in both lumpectomy + tamoxifen
+ RT vs lumpectomy + tamoxifen arm
SUPRACLAVICULAR RADIATION

 Large tumors more than 5 cm

 > 4 axillary nodes (1 – 3 nodes)
 High level positive axillary nodes
 N3

 Total dose: 50 Gy/ 25 #

POST MRM RADIATION

Absolute Indications:
 Tumor more than 5cm.
 Positive/close margin
 > 1 axillary nodes
 Skin, fascial or skeletal muscle
invasion
 Internal mammary node
POST MRM RADIATION

Relative Indications:
 Extra capsular extension
 Poorly differentiated tumors
 Lympho vascular invasion
 Age less than 40 years
 ER, PR negative status
 POST MRM RADIATION

2D(2 Dimensional)
3D CRT
IMRT
Electron beam therapy.

Total dose : 50 Gy/ 25 #

Electron beam therapy- 3D tech

 Usually, 5–8 MeV

electrons are used
 CT planning is used to
determine chest wall
thickness to avoid harm
to excess lung tissue
 Use of bolus increases
the surface dose
AXILLARY RADIATION

No axillary dissection.

Sentinel node biopsy
1-3 axillary nodes with incomplete axillary
dissection
Extra lymphatic extension
>4 axillary LN – high level nodes positive
IMR RADIATION
Indications:
 Primary tumor in medial quadrant
 CS location, more than 3cm
 N3 at presentation
 When internal mammary nodes are
radiologically or clinically detected
 Total dose: 50 Gy/25 #
Complications
 Increased risk of cardiac complications
 Toxic cardiac effects, primarily CHF ( Risk 3.2%)
THANK YOU