EBCTCG METAANALYSIS INDICATION OF POST OP RADIOTHERAPY Immobilization devices Conventional planning Alignment of the Tangential Beam with the Chest Wall Contour Doses To Heart & Lung By Tangential Fields

1. Radiation Therapy in
carcinoma breast
Made by:Dr. Isha Jaiswal
Guided by: Dr. Sandeep Barik
Date: 31st march 2014

2. Aim of radiation therapy
improve loco regional control
improve overall survival

3. EVIDENCES FOR POST-OP
RADIOTHERAPY

4.  Investigated the role of radiation in breast cancer.
 Information was available on 42 000 women in 78 randomised treatment comparisons
 RESULTS:
 In these trials, avoidance of a local recurrence after BCS and mastectomy led to decrease 15-year breast cancer
mortality.
 CONCLUSION
Adequate local treatment will avoid about one breast cancer death over the next 15years for
every four local recurrences avoided, and should reduce 15-year overall mortality.

5. EBCTCG Lancet 2005; 366: 2087-2106 5
Effect of radiotherapy after breast-conserving surgery
(10 trials of BCS  RT) on local recurrence and on breast cancer
mortality
1214 women with node-positive disease
Effect of radiotherapy after breast-conserving surgery
(10 trials of BCS  RT) on local recurrence and on breast cancer
mortality
6097 women with node-negative disease
There were 7300 women with BCS in trials of  RT
 5-year local recurrence risks (mainly in the conserved breast):7% vs 26% (reduction 19%)
 15-year breast cancer mortality risks:30.5% vs 35.9% (reduction 5.4%, SE 1.7, 2p=0.002)
 15-year overall mortality risks:35.2% vs 40.5% (reduction 5.3%, SE 1.8, 2p=0.005)

6. EBCTCG Lancet 2005; 366: 2087-2106 6
Mastectomy and axillary clearance: N-ve
5-year local recurrence risks:
• 2% vs 6%
• (reduction 4%)
15-year breast cancer mortality
risks:
• 31.3% vs 27.7%
• (increase 3.6%, SE 3.6,
2p=0.01)
15-year overall mortality risks:
• 42.4% vs 38.2%
• (increase 4.2%, SE 2.7,
2p=0.0002)
Effect of radiotherapy after mastectomy and axillary clearance (25 trials of Mast+AC  RT) on local
recurrence and on breast cancer mortality
1428 women with node-negative disease

7. EBCTCG Lancet 2005; 366: 2087-2106 7
Mastectomy and axillary clearance: N+ve
5-year local recurrence risks:
• 6% vs 23%
• (reduction 17%)
15-year breast cancer
mortality risks:
• 54.7% vs 60.1%
• (reduction 5.4%, SE 1.3,
2p=0.0002)
15-year overall mortality risks:
• 59.8% vs 64.2 %
• (reduction 4.4%, SE 1.2,
2p=0.0009)
Effect of radiotherapy after mastectomy and axillary clearance (25 trials of Mast+AC  RT) on local recurrence
and on breast cancer mortality
8505 women with node-positive disease

8. 10801 women
17 RCTs
Role of RT after BCS
67% were pathologically node negative disease

9. In women with pN0 disease 67% (n=7287),radiotherapy reduced
 10 year Recurrence risks from 31·0% to 15·6% (absolute recurrence reduction 15·4%, 13·2–17·6, 2p<0·00001)
 15 year Mortality reduction from 20·5% to 17·2% (absolute mortality reduction 3·3%, 0·8–5·8, 2p=0·005)

10. In women with pN+ disease (n=1050), radiotherapy reduced
 10-year recurrence risk from 63·7% to 42·5% (absolute reduction 21·2%, 95% CI 14·5–27·9, 2p<0·00001
 15-year risk of breast cancer death from 51·3% to 42·8% (absolute reduction 8·5%,1·8–15·2, 2p=0·01).

11. Overall, radiotherapy reduced
 10-year risk of any (ie, locoregional or distant) first recurrence
from 35·0% to 19·3% (absolute reduction 15·7%, 95% CI 13·7–17·7, 2p<0·00001)
 reduced the 15-year risk of breast cancer death from 25·2% to 21·4% (absolute reduction 3·8%, 1·6–6·0,
2p=0·00005).

12. aimed to assess the effect of radiotherapy in women with only one to three
lymph nodes positive after mastectomy and axillary dissection.

13. For 700 women with
Mastectomy + AND
RT had no significant effect on
 locoregional recurrence
 overall recurrence
 breast cancer mortality

14. For 1772 women with axillary dissection and four or more positive nodes,
radiotherapy reduced
 locoregional recurrence (2p<0·00001),
 overall recurrence (RR 0·79, 95% CI 0·69–0·90, 2p=0·0003),
 breast cancer mortality (RR 0·87, 95% CI 0·77–0·99, 2p=0·04).

15. For 1314 women with axillary dissection and one to three positive nodes,
radiotherapy reduced
 locoregional recurrence (2p<0·00001),
 overall recurrence (RR 0·68, 95% CI 0·57–0·82, 2p=0·00006),
 breast cancer mortality (RR 0·80, 95% CI 0·67–0·95,2p=0·01).

16. Indications of adj. RT
• All cases of BCS.
• Cases of MRM wherein
i. ≥1 positive axillary LN/s
ii. T3
iii. T4 disease

17. Treatment Planning
OBJECTIVE :
• Deliver uniform dose distribution throughout target volume
• ensure adequate tumor coverage
• minimize doses to normal tissue

18. TECHNIQUE FOR RADIOTHERAPY
Positioning
Immobilization
Simulation
Target Volume
Treatment Planning
Dose & Fractionation
Set Up Verification
Sequelae Of Radiotherapy

19. Positioning & Immobilization
most crucial parts of RT treatment for
 accurate delivery of a prescribed radiation dose
sparing surrounding critical tissues
primary goal:
other benefits :
1) can reduce time for daily set up.
2) make patient feel more secure & less apprehensive.
3) help to stabilize relationship between external skin marks & internal structures
1) reproducibility of position
2) reduce positioning errors

20. TREATMENT POSITION
Supine
Prone
Older techniques
 Lateral
 erect
• Most important aspect of positioning - patient comfort & reproducibility.

21. Positioning devices
• Breast board
• Wing board

22. Breast Board
breast board is an inclined plane with
fixed angle positions
the ant. chest wall slopes downward
from mid chest to neck
brings the chest wall parallel to
treatment couch
the inclination is limited to a 10–15°
angle for 70 cm, and 17.5–20° for
larger 85 cm aperture ct scanners

23. • Several adjustable features to allow for the manipulation of
patients arms, wrists, head & shoulders.
• make chest wall surface horizontal,
• brings arms out of the way of lateral beams..
• Thermoplastic breast support can be added for
immobilization of large pendulous breast
• Constructed of carbon fiber which has lower attenuation
levels permitting maximum beam penetration.
Advantages of breast board

24. Wing board
 Simpler positioning device
 Can be used in narrow bore gantry
 Chest wall slope cannot be corrected
 Need other techniques for reducing dose to heart and field
matching

25. Other treatment positions
• Prone
• Requires patient to climb onto a
prone board, lie on the stomach &
rest the arms over the head.
• The i/l breast gravitates through a
hole in the breast board & c/l breast
is pushed away against an angled
platform to avoid the radiation
beams

26. Prone breast board
System includes:
Prone board
Face cushion
15 Degree Contralateral Wedge
Handles

27. advantages

28. A systematic review of methods to immobilise breast tissue during adjuvant breast irradiation
Sheffield Hallam University Research Archive

29. Immobilization devices
Thermoplastic shells
Adhesive tape
Vac lock
Alpha cradle
Wireless bra
Breast ring
Breast cup
Stocking
Vacuum
L-shaped breast plate

30. For large pendulous breast
• Patients with large or pendulous breasts treated supine require a breast support, either
with a thermoplastic shell, or breast cup which can be used to bring the lateral and
inferior part of the breast anteriorly away from the heart, lung and abdomen.

31. ring device
Breast ring with valecro
The ring consisted of a hollow PVC tube wrapped around the base of the
breast and supported by a Velcro strap

32. Vac-lock
Alpha cradle

33. Simulation
• Where available, CT scanning has become standard for
planning breast radiotherapy
• Scar & drain sites identified with radiopaque markers.
• field borders are chosen & radiopaque wires are placed
• Radiopaque wires is also placed encircling breast tissue
• CT data are acquired superiorly from neck and inferiorly up to diaphragm
• Slice thickness should be sufficient (usually 5 mm) but dependent on agreed local
CT protocols
• Three reference tattoos are placed on the central slice and in right & left sides so
that measurements can be made to subsequent beam centres

34. Supine:
• Most patients are treated in the supine position, with the arm/s abducted and face turned
to the C/L side
• breast tilt boards with armrests used for positioning
• immobilization devices (e.g., Alpha cradle, plastic moulds) can be used
patient immobilized for breast irradiation on a slant board with custom mold

35. POSITION OF ARMS
• The preferred arm position is bilateral arms to be abducted 90 degrees or greater & externally
rotated
• Arm elevation required to facilitate tangential fields across the chest wall without irradiating the
arm.
• Advantages of raising both arms vs only the I/L arm
• Factors deciding the angle of arm elevation
i) Ability to elevate without discomfort.
ii) No/Minimal skin folds in the Supraclavicular region.
iii) Ability to move the patient through the CT aperture.
i. patient is more comfortable and relaxed
ii. position is more symmetrical and easily reproducible with lesser chances of rotation of the torso
iii. more precise matching of the previously irradiated field if c/l breast requires radiation in future

36. Position of head:
• rigid head holder or a neck rest can be used to
stabilize & position head
• also elevate the chin to minimize neck skin folds
within the SCF field

37. Treatment planning
• Conventional
• Three-Dimensional Conformal
• Intensity-Modulated Radiation
Therapy

38. Treatment volumes
• AFTER BCS
• Whole breast radiotherapy + lumpectomy
boost
• Regional nodes
• Accelerated Partial breast irradiation
• AFTER MASTECTOMY
• chest wall,
• mastectomy scar,
• regional nodes

39. 2D based planning

40. Conventional planning
• positioning & immobilization
• Technique
• field borders
• simulation: fluoroscopy or ct based
• Setting medial & lateral tangential beams
• beam modification
• field matching

41. POSITIONING
• Breast board
• Supine with anterior chest wall
parallel to couch
• Arms overhead and comfortable
• If 2 field: patient looks straight
• If 3- field technique: turn the
head to the opposite side to be
treated.

42. TECHNIQUE for WBRT
• Two tangential fields are used.
• Additional fields for SCF, IMC, & post. Axillary may be used

43. Field borders For tangential fields
• Upper border –
• when supra clavicular field used - 2nd ICS (angle of Louis)
When SCF not irradiated – head of clavicle
• Medial border – at or 1cm away from midline
• Lateral border – 2-3cm beyond all palpable breast tissue – mid
axillary line
• Lower border – 2cm below inframammary fold
• Borders can be modified in order to
• cover entire breast tissue,
• to include nodal volumes and scar marks DO NOT MISS THE TARGET VOLUME

44. • Lead wire placed on lateral border
• Field opened at 0⁰ rotation on chest wall and central axis placed along medial border of
marked field
• Gantry rotated , until on fluoroscopy, central axis & lead wire intersect – angle of gantry at
that point is noted – medial tangent angle
• Lateral tangential angle is 180 °opposite to medial tangent
• Simulation film is taken
Deciding angle of rotation of
gantry for tangential fields

45. • After setting simulator at
the isocentre, the gantry is
rotated medially till the
field light corresponds to
the medial border drawn.
• A simulation film is then
taken in this position.
• A wire is placed over the lateral border so that it can be identified on
fluoroscopy/X-ray.
This represents intended posterior border of exit of the medial tangential beam.

46. • Check whether the entire breast is
covered in portal.
• Whether there is a margin of 1.5-2
cms beyond the breast for respiratory
excursion
• Whether there is 1 to 3 cm of lung
visible on the simulation film in the
field anterior to the posterior field
edge.
• Whether the lead wire coincides with
the posterior edge of the portal.

47. Beam Modification Devices in breast
radiotherapy
 Wedges
 Compensators
 Bolus
WBRT uses tangential field technique; however, dose
distribution is complicated because of
 irregularities in the chest-wall contour
 varying thickness of the underlying lung tissue.
Therefore beam modification is required to improve dose
planning target volume (PTV) should be within the 95% and
107% isodose for homogenous dose distribution

48. Wedge Filters
• beam modifying device
• causes progressive decrease in intensity across the beam, resulting in
tilting the isodose curves from their normal positions.
• Degree of the tilt depends upon the slope of the wedge filter.
• Wedges Are Used As Compensators In Breast Radiotherapy.
• Dose uniformity within the breast tissue can be improved
• Preferred in the lateral tangential field than the medial
.

49. Higher dose to the
apex without
wedges
Wedges alter dose distribution only in the transverse direction
and not in the sagittal direction of the bitangential fields.

50. Compensators
• Wedges cannot compensate for a change in breast
shape in the cranio-caudal direction
• Compensators are used to allow normal dose
distribution data to be applied to the treated zone,
when the beam enters obliquely through the body
• advantages
• evens out the skin surface contours, while
retaining the skin-sparing advantage.
reduction in the hot spot

51. Bolus
• A tissue equivalent material used to reduce the depth of the maximum dose (Dmax).
• Better called a “build-up bolus”.
• In MV radiation bolus is used to bring up the buildup zone near the skin
 Increases dose to skin & scar after mastectomy
 In PMRT 3- to 5-mm bolus is used over the chest wall every other day or every day for 2
weeks (20 Gy total dose) and then as needed to ensure that a brisk radiation dermatitis
develops
 Cosmetic results may be inferior
 Universal wax bolus used

52. Alignment of the Tangential Beam with the Chest Wall Contour
• following can be used to make the posterior edge of tangential beam
follow chest contour
Rotating Collimators,
Breast Board:
Multileaf Collimation.

53. Sloping surface of chest wall • Due to the obliquity of the anterior chest wall,
the tangential fields require collimation so as to
reduce the amount of lung irradiated.
Rotating Collimators: collimator of the tangential beam may be rotated

54. The need for collimation can be eliminated if the
upper torso is elevated so as to make the chest wall
horizontal.
This is done by BREAST BOARD
However in a collimated field, junction matching
between the bitangential fields and the anterior SCF
field becomes problematic resulting in hot/cold
spots.

56. consists of two banks of tungsten leaves, situated
within the path of the treatment beam, which
individually move under computer control
Can be moved automatically independent of each
other to generate a field of any shape
multileaf collimator (MLC)

57. Selection of appropriate energy
X-ray energies of 4 to 6 MV are preferred
Photon energies >6 MV underdose superficial tissues beneath the skin surface
If tangential field separation is >22 cm :significant dose inhomogeneity in the breast
So higher-energy photons (10 to 18 MV) can be used to deliver a portion of the
breast radiation (approximately 50%) as determined with treatment planning to
maintain the inhomogeneity throughout the entire breast to between 93 and 105%.
IMRT techniques such as field-in-field or dynamic multileaf collimators (MLCs)
may be utilized to reduce dose inhomogeneity

58. Dose of radiation
Perez & Brady's Principles and Practice of Radiation Oncology, chapter 56, p1089
Whole breast radiotherapy/chest wall irradiation
• Conventional Dose
• 50 Gy in 25 daily fractions given in 5 weeks
• Hypofractionated dose schedule
• 40 Gy in 15 daily fractions of 2.67 Gy given in 3 weeks.
• 42.5 Gy in 16 daily fractions of 2.66 Gy given in 31⁄2 weeks.
Breast boost irradiation to Tumour bed
• 16 Gy in 8 daily fractions given in 1.5 weeks.
• 10 Gy in 5 daily fractions given in 1 week
Lymph node irradiation
• 50 Gy in 25 daily fractions given in 5 weeks
• 40 Gy in 15 daily fractions of 2.67 Gy given in 3 weeks.

59. Doses To Heart & Lung By Tangential Fields
• The amount of lung included in the irradiated volume is greatly
influenced by the portals used.
• Various parameters are used to determine he amount of lung & heart in
tangential field

60. • CLD: perpendicular distance from the posterior tangential field edge to the posterior part of
the anterior chest wall at the center of the field
• MLD: maximum perpendicular distance from the posterior tangential field edge to the
posterior part of the anterior chest wall
Central lung distance marked on the digitally reconstructed radiograph (a) and on
the central axial slice (b)

61. Central lung distance
• Best predictor of %age of ipsilateral lung vol.
treated by tangential fields
CLD (cm) % of lung
irradiated
1.5 cm 6%
2.5 cm 16%
3.5 cm 26%
Usually up to 2 to 3 cm of underlying lung
may be included in the tangential portals
Radiation pneumonitis risk <2% with CLD<3 cm.
Risk upto 10% with CLD 4-4.5 cm.

62. To prevent excess volume of lung irradiated, the divergence of the deep
margins is matched.
2 ways
- angle the central axes slightly more than 180⁰
- half beam block technique.
In very large breasts, bitangentials are unable to cover the target volume
without significantly increasing the volume of OARs irradiated.
MATCHING DIVERGENCE OF PHOTON BEAM

63. angle the central axes slightly more than 180⁰

64. half beam block technique.
By moving one of the independent jaws to midline, a half
beam block can be created.
This forms a non-divergent field edge centrally.
The half beam block functions is easier to set up (less
movements of the couch/gantry)

65. Dose to heart can be minimized by
Median tangential breast port
Cardiac block & electron field
breath hold
gating
When the CLD is >3 cm, in treatment of
the left breast, a significant volume of
heart will also be irradiated
MAXIMUM HEART DISTANCE: maximum perpendicular distance from the
posterior tangential field edge to the heart border

66. A and B: Left tangential breast field with heart block to shield left ventricle from radiation port. Projection of heart block
on breast shields minimal amount of breast tissue.
If necessary, a shadow electron field may be added to cover the portion of breast tissue shielded by heart block
HEART BLOCK

67. Irradiation Dose to the Contralateral Breast
• radiation dose to the contralateral breast is of concern due to potential long-term
carcinogenic effect of scattered radiation.
• this risk appears to be minimal with modern techniques,.
• Use of tangential fields only resulted in more dose delivered to the surface of the opposite
breast,
• whereas use of the internal mammary field in addition to the tangential portals gave more
dose deeper in the breast.

68. Following are helpful in decreasing the dose to the contralateral breast.
• The use of half-field blocks (beam splitter),
• independent jaws
• MLC following the contour of the chest wall of the patient
• wedges on the lateral tangential fields rather than on the medial
• 2.5-cm-thick lead shield over the contralateral breast during treatment with a
medial tangential field

69. Irradiation of Regional Lymphatic
• Supraclavicular Lymph Nodes
• Axillary Lymph Nodes
• Posterior Axillary Boost
• Internal Mammary Lymph Nodes

70. SCF L.N IRRADIATION
Indications of RT to Supraclavicular group:
• N2 or N3 disease
• >4 positive lymph nodes after axillary dissection
• 1-3 positive lymph nodes with high risk features
• Node positive sentinel lymph node with no dissection
• High risk with no dissection
Perez & Brady's Principles and Practice of Radiation Oncology, chapter 56, p1091

71. SCF field
• Single anterior field is used.
Field borders –
• Upper border : thyrocricoid groove
• Medial border : at or 1cm across midline extending
upward following medial border of SCM ms to
thyrocricoid groove
• Lateral border: just medial to the humeral head,
insertion of deltoid muscle
• Lower border : matched with upper border of
tangential fields usually just below clavicle head
field is angled approximately 10 to 15 degrees laterally to spare the cervical spine
dose: calculated at a depth of 3 cm
For obese patients target is deeper than 3 cm, higher energy or AP-PA field can be used

72. • Images of a radiation treatment field used to treat the axillary apex/ SCF.
• The level III region of the axillary and the upper internal mammary vessels have been
contoured
• These contours are used to determine depth of dose prescription
Humeral head
shielding

73. • A hot spot caused by divergence of the tangential & the SCF field at the
junction
• This may result in severe match line fibrosis or even rib fracture.
• There are numerous methods to adjust for divergence
• The divergence of fields can be eliminated by
angling the foot of the treatment couch away from the radiation
Collimator rotation
Hanging block
Half beam block
Matching SCF & chest wall fields

74. Angulation: angling the foot of the treatment couch away from the
radiation source direct the tangential beams inferiorly so that the
superior edges of these beams line up perfectly with the inferior
border of the supraclavicular field
Half beam block technique: Blocking the supraclav field’s inferior
half, eliminating its divergence inferiorly .
Hanging block technique: Superior edge of tangential beam made
vertical by vertical hanging block.
Matching SCF & chest wall fields

75. Monoisocentric matching technique.
Single isocenter is set at the match between the supraclavicular and tangential fields.
 inferior portion of the beam is blocked for
SCF treatment & superior blocked for
tangential field, with no movement of the
isocenter
 Blocks are drawn as indicated to shield
lung and heart.
 The field should be viewed clinically to
ensure that the blocks drawn not block
target tissue on the breast–chest wall.

76. AXILLARY L.N IRRADIATION
 High risk with no dissection
 Sentinel lymph node positive with no dissection
 Inadequate axillary dissection
 Node positive with extensive extra capsular extension
 1-3 positive nodes with unfavorable histology
Indications of RT to axilla

77. Perez & Brady's Principles and Practice of Radiation Oncology, chapter 56, p1091
 Level I & portion of level II nodes included in tangential field;
 level III nodes are covered in SCF field
 Modifications in the tangential & axillary field can be done for better
coverage of axillary nodes
 Depending on the dose distribution and patient’s anatomy, a posterior
axillary boost may be considered

78. MODIFICATION IN TANGENTIAL FIELD: HIGH TANGENT
Field border:
Cranial edge:2 cm below humeral head
Deep edge: 2 cm lung from chest wall interface
Covers 80% of level I/II node

79. • Usually the lateral border of SCF field is just medial to
the humeral head
• when the axilla is treated supraclavicular field is
extended laterally
 to cover at least two-thirds of the humeral head,
Insertion of deltoid or up to surgical head of humerus
MODIFICATION IN SCF FIELD

80. POSTERIOR AXILLARY BOOST

81. • Field border
• Medial border – allow 1.5-2cm of lung on
portal film
• Inferior border – inferior border of s.c field
• Lateral border – just blocks fall off post
axillary fold
• Superior border – splits the clavicle
• Superolaterally – shields or splits humeral
head
• Centre – at acromial process of scapula

82. • The posterior axillary boost has been employed
to supplement axillary dose.
• At the end of the treatments to SCF field, the
dose to the midplane of the axilla may be
supplemented by a posterior axillary field
• When indicated, a boost of 10 to 15 Gy is
delivered with reduced portals

83. INTERNAL MAMMARY NODAL IRRADIATION

84.  Indications of RT to Internal Mammary nodes
• Positive axillary lymph nodes with central & medial lesions
• Stage III breast cancer
• Positive sentinel lymph nodes in IM chain
• Positive SLN in axilla with drainage to IM on lymphoscintigraphy
Perez & Brady's Principles and Practice of Radiation Oncology, chapter 56, p1091

85. IMC field
• Several techniques used
• wide or deep tangents:
• direct anterior field matched to tangential fields

86. wide tangential fields
• The nodes in the first three intercostal spaces are thought to be
most clinically significant.
• The medial border of the tangential field is moved 3 to 5 cm
across the midline to cover the internal mammary nodes in the
first three intercostal spaces
• To minimize lung and cardiac exposure, block can be used

87.  More normal tissue is being irradaited. (lung, heart and contralateral breast
 Field matching not required
Wide tangential fields

88. SEPARATE IMC FIELD
4 field technique
• Anterior field
Medial border – midline
Lateral border – 5-6cm from midline
Superior border – inferior border of SCF
-lower border of clavicle
Inferior border – at xiphoid
or higher if 1st three ICS covered
Depth:4-5 cm

89. Issues with direct anterior field (large breasted women)
When an internal mammary field is required, the match between it and the medial tangential field can be a problem if
there is a significant amount of breast tissue beneath the match line.
Diagrams showing several relationships between internal mammary and tangential fields.
A: cold region exists if internal mammary (IM)- tangential matchline overlies large amount of breast tissue.
B: The cold area may be negligible if the breast tissue beneath the matchline is thin.
C: it can be avoided by including the internal mammary nodes in the tangential field. but can result in
irradiation of an excessive volume of lung

90. oblique incidence of IMC portal match the orientation of
the adjacent medial tangential portal;
this results in a more homogeneous dose distribution at
the junction of the two fields
FIGURE:
A: An obliquely incident electron beam matched to the
usual tangential beams.
B: Isodose presentation of optimal matching of an
obliquely incident electron beam to the tangential beams.
The target volume is enclosed by the 90% isodose line
Electron beam 16 MeV; photon beam, 6 MV..
OBLIQUE IMC FIELDS

91. • Photon-Electron Combination:
• To spare underlying lung, mediastinum,
and spinal cord, electrons in the range of
12 to 16 MeV are preferred for a portion
of the treatment,
• for example 14.4 to 16.2Gy delivered with
6MV photons and 30.6 to 32.4 Gy with
electrons

92. two medial electron fields were angled 15 degrees toward a matched pair of photon fields.
energy of upper electron field is higher than that of the lower electron field in order to achieve
coverage of the contoured internal mammary target while minimizing the dose to the heart
Skin surface rendering of the fields. Lower axial image in region of heart.Upper axial image.
: Electron -Electron Combination IMC field in PMRT
Images of radiation treatment fields to treat the chest wall and IMC

93. Junctional electron field technique
particularly of benefit for patients with very little tissue between the lung and skin
use three electron fields. These fields are then match to a supraclavicular/axillary apex field
Three medial electron fields are matched on the skin.
The junction between the middle and lateral fields is shifted weekly due to the differences in gantry angle.
A: Skin surface rendering of the fields. B: Axial image of the fields

94. Boost to Tumor Site after WBRT in BCS
• Rationale : Local recurrences tend to be primarily in and around the
primary tumor site – boost  risk of marginal recurrence.
• More advantageous when margins unknown & young women less than
40 yrs but benefit seen in all age gp
• Given by either EBRT or Brachytherapy
• EBRT : Photon, Electrons
• Brachytherapy
• ISBT : Rigid / Catheter
• IC Lumpectomy cavity : Mammosite etc

95. Localization of lumpectomy cavity
Various techniques of localizing the tumour bed
include:
 CT scan
 MRI
 USG
 pre op MMG
 Surgical scar/ pT size

96. Localization of lumpectomy cavity
The combination of surgical clips with a treatment planning CT is most
ideal.
In the absence of surgical clips,
CT scan of biopsy cavity or postsurgical changes, in combination with
clinical information including mammography, scar location, operative
reports, and patient input, provide accurate information regarding
placement of the field and energy of the electron boost.

97. •lumpectomy cavity + a margin of 2 cm in all directions = approximate
size of boost field.
•The margins of this field are marked on the skin with the centre of the
scar as the centre of field

98. Boost-electrons
• the accelerator head point straight down onto the target volume
• Electron energy selected –
• 90% isodose should cover tumor bed.(usual range is 9 to 16 MeV
electrons).
• the approximate energy of electron required to reach a depth of x cm will
be (4*x) MeV.
• Dose – 10-20Gy @ 2Gy/#
• electron beam boost preferred because of
• its relative ease in setup,
• outpatient setting,
• lower cost,
• decreased time demands on the physician,
• excellent results compared with 192Ir implants

99. Boost photon • mini tangential fields used to boost
target volume

100. Interstitial boost:
• 1 or 2 planes of needles are usually needed
to cover the PTV depending upon size
• Needles are implanted parallel and equidistance from each other (Paris system).
• In most cases inserted in a mediolateral direction.
• In very medially or laterally located tumor sites, needles should be implanted in a
craniocaudal direction .to enable separate target area from skin points.
• In some rare cases, the upper outer quadrant has to be implanted with needles orientated
in a 45° angle to avoid overlap of source positions and skin

101. beam matching can be difficult
Dosimetry performed only on in the midplane of the target volume.
Dose distribution can be inhomogenous away from the central axis (superoinferiorly),
especially in large breasts.
Doses to the OARs (Heart and lung) cannot be determined accurately.
Shielding of heart while treating the left breast, won’t ensure whether a part of the
target volume is being missed.
DISADVANTAGES OF 2D PLANNING

102. Three-Dimensional Conformal Radiation Therapy
• Standard opposed tangential fields with appropriate use of wedges to
optimize dose homogeneity remains the most commonly employed
method for delivery of whole-breast irradiation
• 3DCRT may improve dose to target volume & reduction in dose to
normal tissues & critical organs
• Better cosmetic results
• Less dose to heart and lung

103. 3-Dimensional planning
• Simulation
• Plain CT scan of 5mm
slice thickness is taken
from the neck to just
below diaphragm.
• Contouring
• Field set up

104. Breast contouring guidelines for conformal CT
based planning
• The RTOG has come up with a Breast Cancer Atlas.

105. LABC: after
NACT & BCS
after
mastectomy
after BCS

106. Breast-superior Breast-inferior
Breast CTV after lumpectomy

107. Chest wall CTV after MRM

108. Regional nodal contouring

109. SCF begins SCF ends

110. SCF LEVEL III

111. LEVEL II

112. LEVEL I

113. IMC node

114.  Lumpectomy GTV: Surgical cavity from lumpectomy. Contour using all available
clinical and radiographic information including the cavity volume, lumpectomy scar,
seroma and surgical clips
 Lumpectomy CTV: GTV +1 cm margin 3D expansion
 Lumpectomy PTV: CTV+ 7 mm 3D expansion exclude heart

115.  Lumpectomy PTV eval :

116.  Breast CTV: Includes all palpable breast tissue. Takes into account clinical borders at the time of CT
simulation.
Limited anteriorly within 5 mm from skin & posteriorly to the anterior surface of the chest wall
 Breast PTV: Breast CTV + 7 mm expansion
–Used for beam aperture generation
 Breast PTV-EVAL: Clipped 5 mm into skin anteriorly and no deeper than the anterior surface of the ribs
posteriorly (excludes bony thorax and lung)
–Used for DVH analysis

118. Role of IMRT in breast radiotherapy

119. IMRT Breast:
• Dosimetric advantages:
(1) better dose homogeneity for whole breast RT
(2) better coverage of tumor cavity
(3) feasibility of SIB
(4) Decrease dose to the critical organs
(5) Left sided tumors- decrease heart dose
Disadvantages:
may increase the volume of tissue exposed to lower doses of radiation.
may increase the risk of second malignancies

120. • Reduces the hotspots specially in the
superior and inframammary portions
of the breast.
Increases homogenity
Manifests clinically into decrease in
moist desqumation in these areas.

122. INVERSE PLANNING
Inverse planning is a technique using a computer program to
automatically achieve a treatment plan which has an optimal merit.
target doses & OAR constraints are set
Then, an optimisation program is run to find the treatment plan which
best matches all the input criteria.
IMRT PLANNING: forward vs inverse

123. Forward planning IMRT: field within field
• Advancement to conventional 3DCRT
• In this technique a pair of conventional open tangential fields is produced first
• MLCs are used to shape the fields & spare OARs
• Wedge angle & relative weight of beams optimized to produce plan
• To ovoid hotspots and large doses to OAR & to obtain a homogenous dose
distribution (range 95-107%) the dose delivered with open fields is reduced to 90-
93% of total dose
• new tangential beam with same gantry & wedge angles are designed for remaining
dose
• The new reduced field are shaped to exclude areas receiving more than 105% of
dose.
• The other approach is to delineate regions of non uniform dose by contouring
isodose lines

124. Forward planned IMRT (field-in-field) is preferred
• Breast dosimetry can be significantly improved
• Better cosmetic outcomes
• simple method
• Less MU
• Less scatter
• Decreased planning time
• Decreased treatment time

125. Forward plan IMRT

126. ACCELERATED PARTIAL BREAST IRRADIATION
 PARRIAL BREAST IRRADIATION: The target
volume irradiated is only the post lumpectomy tumor bed
with 1-2cm margin around
ACCELERATED DOSE DELIVERY: the dose is
delivered in a shorter interval than the standard 5 – 6 weeks
Treatments delivered twice daily (with treatments separated
by six hours) for 10 treatments delivered in 5 treatment days.

127. RATIONALE OF APBI
(1) Most breast cancer recurrences occur in the index quadrant:
higher dose of RT can be given than by conventional RT
(2) Many patients cannot come for prolonged 5-6 week adjuvant radiotherapy for
logistic reasons:
reduces overall treatment period considerably
Patient convenience may increase acceptance of radiation treatment after breast-
conservation surgery

128. INDICATIONS OF APBI:
ASTRO APBI CONSENSUS STATEMENT

130. APBI: modalities
HDR interstitial brachytherapy
Intracavitary brachytherapy :Mammosite
3DCRT/IMRT
Intra-operative electrons (ELIOT) or orthovoltage X rays (TARGIT)

131. Accelerated Partial Breast Irradiation
Benefits:
Larger dose can be delivered to small area
Limited radiation exposure to normal tissue
Treatments completed in one week instead of six weeks
Limitations:
May require additional surgical procedure
Requires twice daily treatment
Newer modality with far fewer patients treated and much shorter follow-up

132. Target should be small (less than 2 cm size with 2 mm margins & at
least 7mm. of tissue between the catheter surface and the skin)
multiple catheters are generally positioned at 1- to 1.5-cm intervals,
total number and planes dependent on the size, extent, and shape of the
target.
Post BCS the catheters are implanted immediately or after 2 – 3 weeks
in the lumpectomy site
Simulation is done with CT imaging and transferred to the TPS
Loading of source, position and dose distribution is decided in the TPS
Dose – 34 Gy in 10 # , 3.4 Gy per # / two # per day / 5 days.

133.  catheter with expandable balloon at end
 Balloon filled with saline mixed with contrast for verify positioning
 expands to fill the lumpectomy cavity
 Radiation dose prescribed to 1 cm beyond balloon surface
 Prescription:34 Gy in 10 fractions over 5 -7days
 Advantage: simple, minimally invasive, offers acceptable cosmetic results, and induces mild side effects
 Disadvantages: Balloon must conform to cavity shape without air gaps.Ideal is to have 7 mm b/w balloon and
skin to decrease risk of erythema.Very dependent on surgical placement
MammoSite PBI

134. Four-field beam arrangement and conformal, homogeneous dose coverage of the target.
This APBI technique with conformal EBRT is attractive to both physician and patient alike because it is
(1) noninvasive,
(2) delivers a homogeneous dose with decreased procedural trauma to the breast
(3) offers a potential reduction in normal breast tissue toxicity
APBI:3DCRT

135. Intraoperative Radiation Therapy (IORT) for PBI
• TARGIT trial is comparing whole breast irradiation to IORT
delivering a single dose of 20 Gy..
• Using the Intrabeam Photon Radiosurgery System, 50 kV xrays
• Intraoperative electrons can also be used with mobile linear
accelerators & cylindrical applicators for electron beam collimation

136. TARGIT

137. ELIOT

138. Partial breast irradiation techniques
Interstitial
Brachyther.
Intracavitary
Brachyther
Intraop.
RT
3D
Conformal RT
Dose 34 Gy in 10 fr
In 5 days
34Gy in 10 fr
In 5 days
20-21Gy in single
fraction
38.5 Gy in 5 fr. In 10
days
Target 1.5 cm margin around
WLE cavity
1cm around
WLE cavity
Visual by surgeon and
rad oncologist perop
2.5cm margin around
WLE cavity
Pros Many dwell positions
for Irreg. cavity
Ease of placement
and planning
Single dose
Spares skin
Fits with standard RT
machines
Cons Operator
dependent
High cost
Fewer dwell
positions
RT before pathology
known
Specialised centres
only
Larger fields
(respiration) and
more normal tissue

139. Sequelae of irradiation in breast cancer
• Lymphedema and Breast Edema
• Skin and Breast Complications
• Brachial Plexopathy
• Pulmonary Sequelae
• Cardiac Sequelae
• Contralateral Breast Cancer and Irradiation
• Incidence of Other Second Malignancies
• Post irradiation Angiosarcoma of the Breast

140. Skin toxicities
• Erythema / Hyperpigmentation (after 20-26Gy total dose at 2Gy/#)
• Dry desquamation till the basal layers can just replace the normal cell
turnover
• Moist desquamation (first patchy and then confluent) later especially
in the regions of folds/ large breasts/ hotspots.
• Hemorrhage, ulceration
• Significantly less with modern radiotherapy
• Treated symptomatically: good aeration, avoid friction, wear loose
fitting cotton clothes

141. Arm Lymphedema
• risk of arm edema increases with axillary dissection and RT
• Sentinel node sampling has much lower degree of lymphedema
• The ALMANAC randomized trial also confirms lower morbidity and
improved quality of life following sentinel node biopsy compared with
axillary dissection.
• Associated with swelling,weakness, limitation in range of movement,
stiffness pain & numbness

142. Treatment of lymphedema
• it is mandatory to differentiate between treatment-associated
complications and tumor recurrence in regional lymphatics
• Various treatment regimens have been used to treat lymphedema.
• The compression pump, along with skin care, exercise, and
compression garments,
• complex decongestive physiotherapy or complex physical therapy.:
Arm care, therapeutic exercises, manual lymph node drainage, and
compression bandages or garments comprise this treatment regime..

143. Breast Complications
Includes
• Breast edema – due to lymphatic obstruction.
• Persistent breast edema- chronic disruption of lymphatics.
• Subcutaneous fibrosis and telangiectasias – d/t late effects of dermal
fibrocytes and vessels
• Increased breast stiffness seen with doses more than 1.8-2 Gy &
concurrent use of tamoxifen
• Affects cosmesis the most.

144. Brachial plexopathy
Incidence:1-2%
possible complication of regional nodal radiation therapy
pain, loss of sensation, muscle weakness ,paralysis muscles of the shoulder and upper
limb
Risk factors includes
 axillary dose was >50 Gy
 concomitant chemotherapy
important to distinguish between metastatic and radiation-induced brachial plexopathy.
Treatment for radiation brachial plexopathy consists of
 transdermal electrical nerve stimulation,
 dorsal column stimulators,
 Physical therapy, tricyclics, antiarrhythmics, anticonvulsives, nonsteroidal anti-inflammatory drugs, and steroids

145. Pulmonary sequalae
• Rate of symptomatic pneumonitis 1-2% after WBRT
• Patients present with dry cough, shortness of breath, rales, pleuritic chest pain or fever and on
radiographic studies a pulmonary infiltrate is observed in the irradiated volume.
• Responds well to steroids
• The risk for development of radiation pneumonitis related to
 age>60 yrs previous lung ds
RT dose, fractionation
volume of lung irradiated.
regional nodal radiation therapy
Concurrent chemo (taxanes) or hormonal therapy
• Apical pulmonary fibrosis is noted when the regional lymph nodes are irradiated.
• Rib fracture also seen in some cases

146. Cardiac sequalae
• may be acute or chronic
• Pericarditis is acute transient but may be chronic
• Late injury includes CHF ,ischemia, CAD,MI
• risk of cardiac toxicity greater in
left-sided breast cancers
patients receiving other cardiotoxic therapies, including adriamycin, epirubicin, and
trastuzumab.
Old RT techniques
IMC irradiation
• Although clinical evidence of cardiac morbidity has decreased with modern techniques,
care should be taken to exclude heart from the tangential radiation field

147. Contralateral Breast Cancer
• Although all patients with a diagnosis of breast cancer are at increased risk for
developing a contralateral breast cancer, the additional risk contributed by
radiation treatment appears to be minimal, with modern techniques
• EBCTCG 2005 overview analysis does suggest an elevated incidence of
contralateral breast cancer in patients receiving radiation compared with those
who did not receive radiation.RR=1.18 (p=.002).
• Although the excess risk appears to be driven primarily by older trials using
antiquated techniques, these data highlight the need to maintain dose to the
contralateral breast as low as possible.

148. EBCTCG Lancet 2005; 366: 2087-
2106 148
Effect of radiotherapy on contralateral breast cancer incidence and on non-breast-cancer mortality (46 trials of
adding radiotherapy, and 17 trials of radiotherapy vs more surgery)
(29 623 women)

149. Incidence of Other Second Malignancies
• Although more prevalent with older techniques, it is an important
component of treatment planning to minimize dose to nontarget normal
tissues.
• EBCTCG overview analysis did demonstrate an excess risk of secondary
cancers of the lung and esophagus as well as leukemia and sarcoma in all
randomized trials of breast cancer that compared patients treated with and
without radiation.
• The total relative risk for all secondary nonbreast malignancies was 1.20
(± 0.06; P = .001).
• Although the increased risk of secondary malignancies may be driven
primarily by trials using older techniques, they highlight the importance of
limiting dose to nontarget tissues.

150. Post irradiation Angiosarcoma of the
Breast
rare but severe long-term complication of pts. treated with
radiotherapy
development has been linked to radiotherapy and lymphedema.
Special attention should be paid to uncommon skin changes of
the treated breast
The primary therapy is simple mastectomy if wide tumor-free
margins can be achieved.

151. Thankyou