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Choice of target volume for brachytherapy boost in locally advanced breast cancer: an Indian experience
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Wednesday, 22 March 2006
indexes are expected to be equal to 1 For IMN, coverage was 0 92 ( • 06): conformity was 0 95 ( • 05) and HI was 1 18 ( • 06) IMN volume irradiated by 95% isodose was 98• For total lung, volume irradiated by the 20Gy isodose was 17 (• The average dose delivered to the total lung volume was 9 5 (• 5) Gy For 8 patients treated on left side, average cardiac dose was 5 (• Gy Skin side effects were mainly grade 1-2 and only one grade 3. With a short median follow up of 12 months, 2 pneumonitis grade 1 have been seen, three months post treatment with complete resolution over 3 months. Two patients have been diagnosed with a Ioco regional recurrence and 2 others with distant metastasis. Conclusion: We have developed and implemented in routine a VCOMP technique to modulate beams and homogenize dose distribution in IMN. Dosimetric results are similar as those reported by intensity modulated radiation therapy (IMRT) with inverse planning A prospective pilot trial to evaluate the role of IMN IMRT with a Tomotherapy Unit, recently installed in our department, is planned 183 Poster The effect of treatment interruptions during postoperative breast irradiation N S Bose R Sut. A Ober /staobul University, Cerrahpasa Medical
School, Department of Radiation Oncology, lstanDul, TurRey Purpose: To determine the outcome of the treatment interruptions dunng postoperative irradiation alter breast conserving surgery, 470 patients treated in the years 1990 2003 inclusive were retrospectively analyzed. Materials and Methods: Median age was 48 years (21-83). Median fellow up was 57 months (8 183). Most common histopathologic diagnosis was invasive ductal carcinoma(82%) Tumor distribution by pathologic T stage was T1:61%,T2:38%,T3:1% All patients received breast conserving surgery, and 12 (2%) patients did not receive axillary lymph node dissection There were no axillary lymph node metastases in 272(58%) patients, 1 3 lymph nodes were. positive in 131(28%). 4 and more lymph nodes were positive in 55(12%) patients All of the patients had breast irradiation with Co60 unit or 4MV Four hundred and sixty two (98%) patients had boost dose to the tumor bed either with photon, electron or interstitial irradiation. Lymphatic fields were selected due to the number of involved nodes. One hundred and seven (22%) patients did not receive systemic treatment, while 131 (28%) patients had hormonal treatment, 144 (31%) had chemotherapy and 88(19%) patients received both chemotherapy and hormonal treatment. Patients were grouped according to the duration of treatment interruption. Grouping will be given in detail Only the groups that had statistically significant results are mentioned in the abstract Group A had 196(41%) patients who had no treatment break or interruptions of 7 days or less Group B had 274(58%) patients who had treatment interruptions of 8 days or more Locoregional control (LC), overall survival (OS). and disease-free survival (DFS) rates were estimated by Kaplan-Meier method Multivariate analyses were done by Cox model testing the parameters age, menopausal status, T-stage, axJllary status, systemic treatment, durat fen of radiotherapy interruption and the number of gaps. Results: For all patients LC,OS and DFS fur 5 years were 91%, 85%, and 76% respectively and 10 years Pates were as follows; 86%,75% and 66%. Local control Pates for group A fur 5 and 10 years were 95% and 90% respectively, and they were 87% and 83% fur group B fur the same years. The difference was statistically significant (p = 0.02). In multivariate analyses age younger than 40 years, premenopausal status, duration of treatment interruptions of 8 days or more and the increased number of gaps appeared to be independent adverse prognostic factors on LC(p 0 04, p 003.p 0 02, p 002 respectively) Conclusion: This retrospective study shows that treatment interruptions of 8 days or more during postoperative breast irradiation had adverse effects on LC 184 Poster Number of positive nodes: no prognostic cutoff in breast cancer treated with mastectomy V Vinh-Hunq. M Voordeckers. G Storme AZ-VUB, Oocolegisch
Centrum, Jette, Belgium Purpose: A cutoff of 4 or more positive lymph nodes is usually considered in the decision for adjuvant radiotherapy after mastectomy in patients presenting with T1-T2 node positive breast cancer We investigate the relationship between the number of positive nodes and survival to determine whether or not population data supports such a prognostic cutoff Material and Methods: Women aged >50 and <65 years presenting with a first pnmary T1 T2 node positive non metastasized unilateral breast carcinoma, diagnosed in 1988-97, were selected from the Surveillance, EpJdemJology, and End Results (9 registries database, release 2004). Patients who received post operative radiotherapy were excluded. Hazard
Poster Sessions ratios were computed for each putative cutoff from 1 to 23 nodes, adjusted in multivariate Cox models by diagnostic year. age, area, race. marital status, histology, grade, hormone receptors, tumor location, size. and nodes examined Outcomes were breast cancer specific and any-cause death Results: The overall mortality hazard ratio of a higher number of involved nodes as compared with a lower number ranged from 1 78 [95% confidence 1.58-1.99] with 1 node cutoff, to 3.65 [2.52-5.29] with 23 nodes cutoff. Breast cancer specific mortality hazard Patio ranged from 1.99 [1.73-2.29] with 1 node cutoff, to 4.63 [3.11-6.91] with 23 nodes cutoff. The graph of the hazard Patios showed a continuously increasing risk of overall and breast cancer specific mortality. The relationship between the putative nodal cutoffs and the multivariate hazard ratios was strictly linear, for overall mortality (R2= 0.94, P <0.0001), and for breast cancer specific mortality (R2 0 97. P <0 0001) There was no identifiable indication to support the choice of any particular cutoff Conclusion: In this selected subpopulation of patients who were treated with mastectomy and who did not receive adjuvant radiotherapy. multivariate analysis showed no prognostic cutoff in the number of positive nodes Of particular concern was the high breast cancer specific mortality hazard ratio even with small number of positive nodes We argue that the number of positive nodes should not be used as an indicator for adjuvant treatment in node positive patients. 185 Poster Choice of target volume for brachytherapy boost in locally advanced breast cancer: an Indian experience S Saha 1 A Ghos Dastidar 2, S Sarkar a,P DasGupta 4,A Roy4, A B a s u 4 ~Medical College Hospital, Calcutta, Radiotherapy, Calcutta,
Irtdia, 2Medical College Hospital, Radiotherapy, Calcutta, india, Thatfurpukur Cancer Center, Radiotherapy, Calcutta, India, 4Medical College Host~taf, Radiotherapy, Calcutta, India Introduction: Interstitial implant is an accepted technique for boost after conservative surgery (BCS) and whole breast radiotherapy (WBRT) in selected locally advanced breast cancer (LABC) after adequate downstaging by neoadjuvant chemotherapy. But as yet there is relative paucity of data, especially as to choice of target volume for boost in LABC. Purpose: Present study was aimed to explore the inlluence of tumor margin for HDR brachytherapy boost in LABC on local control, late toxJcJtJes and cosmesis. PaUents and Methods: Between March 2002 and December 2004, 76 margin negative LABC patients (T3/T4, N0-2, M0) received HDR boost (10 Gy single fraction) after BCS and WBRT (50 Gy) Initially they were downstaged by neoadjuvant FAC chemotherapy for 3 4 cycles Post chemotherapy tumor diameter ranged between 1 2 5cm and depth from skin was > 2 5 cm Before HDR implant patients were randomized, after informed consent, to either 1 5 cm margin around tumor bed (Arm I, n 37) or 3cm margin (Arm II. n 39) Tumor bed was delineated by surgical clips or tumor scar in pre-implant CT scan After template guided rigid implant, CTbased planning was done with geometrical optimization. DVH was analyzed in each for DHI, Coverage index, DNR as well as Confermal index (COIN). PI~/was found to jump from a median 58 ce in Arm I to median 237 cc in Arm II. COIN ranged between 0.62 and 0.89 (median 0.81). Skin dose was calculated in all. After implant all received another 2-3 cycles of FAC. Local control, late toxicity (LEN~SOMA) and cosmetic outcome (assessed by a panel) were recorded in follow up Results: Alter a median FU of 36 months. 3 patients in 1 5 cm arm (Arm I) and 2 in Arm II had in-breast failures (P NS) Distant metastasis occurred in 6 patients in each arm Grade 1 2 fibrosis was noted in 8f37 (21%) in Arm I and 21f39 (54%) in A r m l l ( P 00043) G r l 2 telengiectasia occurred in 3f37 in Arm I vs 5f39 in Arm II (P NS) Grade 3 fibrosis was observed in 2 patients in Arm II and in none in arm I. Regarding cosmetic outcome, 31/37 patients (84%) were good + excellent, 6 fair and none poor in arm I. Corresponding figures in arm II were 19/39 (48%), 11/39 and 9/39 (P=0.0016 fur good + excellent and 0.0029 for poor). Conclusion: 15 mm margin around post chemotherapy volume seems to be adequate PI~/fur HDR boost in margin negative LABC. Higher margin and hence 3 5 fold higher target volume leads to significantly poor cosmetic outcome and increased fibrosis without any extra benefit in local control
Wednesday, 22 March 2006
indexes are expected to be equal to 1 For IMN, coverage was 0 92 ( • 06): conformity was 0 95 ( • 05) and HI was 1 18 ( • 06) IMN volume irradiated by 95% isodose was 98• For total lung, volume irradiated by the 20Gy isodose was 17 (• The average dose delivered to the total lung volume was 9 5 (• 5) Gy For 8 patients treated on left side, average cardiac dose was 5 (• Gy Skin side effects were mainly grade 1-2 and only one grade 3. With a short median follow up of 12 months, 2 pneumonitis grade 1 have been seen, three months post treatment with complete resolution over 3 months. Two patients have been diagnosed with a Ioco regional recurrence and 2 others with distant metastasis. Conclusion: We have developed and implemented in routine a VCOMP technique to modulate beams and homogenize dose distribution in IMN. Dosimetric results are similar as those reported by intensity modulated radiation therapy (IMRT) with inverse planning A prospective pilot trial to evaluate the role of IMN IMRT with a Tomotherapy Unit, recently installed in our department, is planned 183 Poster The effect of treatment interruptions during postoperative breast irradiation N S Bose R Sut. A Ober /staobul University, Cerrahpasa Medical
School, Department of Radiation Oncology, lstanDul, TurRey Purpose: To determine the outcome of the treatment interruptions dunng postoperative irradiation alter breast conserving surgery, 470 patients treated in the years 1990 2003 inclusive were retrospectively analyzed. Materials and Methods: Median age was 48 years (21-83). Median fellow up was 57 months (8 183). Most common histopathologic diagnosis was invasive ductal carcinoma(82%) Tumor distribution by pathologic T stage was T1:61%,T2:38%,T3:1% All patients received breast conserving surgery, and 12 (2%) patients did not receive axillary lymph node dissection There were no axillary lymph node metastases in 272(58%) patients, 1 3 lymph nodes were. positive in 131(28%). 4 and more lymph nodes were positive in 55(12%) patients All of the patients had breast irradiation with Co60 unit or 4MV Four hundred and sixty two (98%) patients had boost dose to the tumor bed either with photon, electron or interstitial irradiation. Lymphatic fields were selected due to the number of involved nodes. One hundred and seven (22%) patients did not receive systemic treatment, while 131 (28%) patients had hormonal treatment, 144 (31%) had chemotherapy and 88(19%) patients received both chemotherapy and hormonal treatment. Patients were grouped according to the duration of treatment interruption. Grouping will be given in detail Only the groups that had statistically significant results are mentioned in the abstract Group A had 196(41%) patients who had no treatment break or interruptions of 7 days or less Group B had 274(58%) patients who had treatment interruptions of 8 days or more Locoregional control (LC), overall survival (OS). and disease-free survival (DFS) rates were estimated by Kaplan-Meier method Multivariate analyses were done by Cox model testing the parameters age, menopausal status, T-stage, axJllary status, systemic treatment, durat fen of radiotherapy interruption and the number of gaps. Results: For all patients LC,OS and DFS fur 5 years were 91%, 85%, and 76% respectively and 10 years Pates were as follows; 86%,75% and 66%. Local control Pates for group A fur 5 and 10 years were 95% and 90% respectively, and they were 87% and 83% fur group B fur the same years. The difference was statistically significant (p = 0.02). In multivariate analyses age younger than 40 years, premenopausal status, duration of treatment interruptions of 8 days or more and the increased number of gaps appeared to be independent adverse prognostic factors on LC(p 0 04, p 003.p 0 02, p 002 respectively) Conclusion: This retrospective study shows that treatment interruptions of 8 days or more during postoperative breast irradiation had adverse effects on LC 184 Poster Number of positive nodes: no prognostic cutoff in breast cancer treated with mastectomy V Vinh-Hunq. M Voordeckers. G Storme AZ-VUB, Oocolegisch
Centrum, Jette, Belgium Purpose: A cutoff of 4 or more positive lymph nodes is usually considered in the decision for adjuvant radiotherapy after mastectomy in patients presenting with T1-T2 node positive breast cancer We investigate the relationship between the number of positive nodes and survival to determine whether or not population data supports such a prognostic cutoff Material and Methods: Women aged >50 and <65 years presenting with a first pnmary T1 T2 node positive non metastasized unilateral breast carcinoma, diagnosed in 1988-97, were selected from the Surveillance, EpJdemJology, and End Results (9 registries database, release 2004). Patients who received post operative radiotherapy were excluded. Hazard
Poster Sessions ratios were computed for each putative cutoff from 1 to 23 nodes, adjusted in multivariate Cox models by diagnostic year. age, area, race. marital status, histology, grade, hormone receptors, tumor location, size. and nodes examined Outcomes were breast cancer specific and any-cause death Results: The overall mortality hazard ratio of a higher number of involved nodes as compared with a lower number ranged from 1 78 [95% confidence 1.58-1.99] with 1 node cutoff, to 3.65 [2.52-5.29] with 23 nodes cutoff. Breast cancer specific mortality hazard Patio ranged from 1.99 [1.73-2.29] with 1 node cutoff, to 4.63 [3.11-6.91] with 23 nodes cutoff. The graph of the hazard Patios showed a continuously increasing risk of overall and breast cancer specific mortality. The relationship between the putative nodal cutoffs and the multivariate hazard ratios was strictly linear, for overall mortality (R2= 0.94, P <0.0001), and for breast cancer specific mortality (R2 0 97. P <0 0001) There was no identifiable indication to support the choice of any particular cutoff Conclusion: In this selected subpopulation of patients who were treated with mastectomy and who did not receive adjuvant radiotherapy. multivariate analysis showed no prognostic cutoff in the number of positive nodes Of particular concern was the high breast cancer specific mortality hazard ratio even with small number of positive nodes We argue that the number of positive nodes should not be used as an indicator for adjuvant treatment in node positive patients. 185 Poster Choice of target volume for brachytherapy boost in locally advanced breast cancer: an Indian experience S Saha 1 A Ghos Dastidar 2, S Sarkar a,P DasGupta 4,A Roy4, A B a s u 4 ~Medical College Hospital, Calcutta, Radiotherapy, Calcutta,
Irtdia, 2Medical College Hospital, Radiotherapy, Calcutta, india, Thatfurpukur Cancer Center, Radiotherapy, Calcutta, India, 4Medical College Host~taf, Radiotherapy, Calcutta, India Introduction: Interstitial implant is an accepted technique for boost after conservative surgery (BCS) and whole breast radiotherapy (WBRT) in selected locally advanced breast cancer (LABC) after adequate downstaging by neoadjuvant chemotherapy. But as yet there is relative paucity of data, especially as to choice of target volume for boost in LABC. Purpose: Present study was aimed to explore the inlluence of tumor margin for HDR brachytherapy boost in LABC on local control, late toxJcJtJes and cosmesis. PaUents and Methods: Between March 2002 and December 2004, 76 margin negative LABC patients (T3/T4, N0-2, M0) received HDR boost (10 Gy single fraction) after BCS and WBRT (50 Gy) Initially they were downstaged by neoadjuvant FAC chemotherapy for 3 4 cycles Post chemotherapy tumor diameter ranged between 1 2 5cm and depth from skin was > 2 5 cm Before HDR implant patients were randomized, after informed consent, to either 1 5 cm margin around tumor bed (Arm I, n 37) or 3cm margin (Arm II. n 39) Tumor bed was delineated by surgical clips or tumor scar in pre-implant CT scan After template guided rigid implant, CTbased planning was done with geometrical optimization. DVH was analyzed in each for DHI, Coverage index, DNR as well as Confermal index (COIN). PI~/was found to jump from a median 58 ce in Arm I to median 237 cc in Arm II. COIN ranged between 0.62 and 0.89 (median 0.81). Skin dose was calculated in all. After implant all received another 2-3 cycles of FAC. Local control, late toxicity (LEN~SOMA) and cosmetic outcome (assessed by a panel) were recorded in follow up Results: Alter a median FU of 36 months. 3 patients in 1 5 cm arm (Arm I) and 2 in Arm II had in-breast failures (P NS) Distant metastasis occurred in 6 patients in each arm Grade 1 2 fibrosis was noted in 8f37 (21%) in Arm I and 21f39 (54%) in A r m l l ( P 00043) G r l 2 telengiectasia occurred in 3f37 in Arm I vs 5f39 in Arm II (P NS) Grade 3 fibrosis was observed in 2 patients in Arm II and in none in arm I. Regarding cosmetic outcome, 31/37 patients (84%) were good + excellent, 6 fair and none poor in arm I. Corresponding figures in arm II were 19/39 (48%), 11/39 and 9/39 (P=0.0016 fur good + excellent and 0.0029 for poor). Conclusion: 15 mm margin around post chemotherapy volume seems to be adequate PI~/fur HDR boost in margin negative LABC. Higher margin and hence 3 5 fold higher target volume leads to significantly poor cosmetic outcome and increased fibrosis without any extra benefit in local control