prone breast

Rachel A . Hacket t CMD, RTT

PRONE BREAST –WHAT’S THE BIG DEAL?

Surgical Options For the breast:

Breast conserving surgery (lumpectomy) Breast Conservation

Therapy = surgery + radiation Mastectomy +/- immediate

reconstruction For lymph node

assessment: Sentinel lymph node biopsy Axillary lymph node

dissection

BREAST CANCER TREATMENT OPTIONS

Systemic therapy options: Chemotherapy Can be given either before or after surgery Neoadjuvant or adjuvant Selection for use depends on stage and extent of disease, type of breast cancer and

features (ER , PR, Her2 status), potential for down-staging to breast conservation, assessment of response

Endocrine therapy / hormonal therapy Examples: tamoxifen, aromatase inhibitors, ovarian suppression

BREAST CANCER TREATMENT OPTIONS

Role of radiation in the setting of breast conservation and post mastectomy:

Improvement in local or locoregionalcontrol

Survival benefit in invasive carcinomas and in the post mastectomy setting Disease free survival Overall survival

RATIONALE FOR RADIATION

TARGETSWhole breastPartial BreastChest wallRegional nodes

RADIATION TREATMENT OPTIONS

DOSE and FRACTIONATION Conventional Fractionation 1.8-2 Gy per fraction to total dose 45-50.4 Gy

Hypofractionation Shorter course utilizing larger doses per fraction >2 Gy per fraction to lower total dose 40.05 – 42.56 Gy given in daily fxs for whole breast 34-38.5 Gy given twice daily fxs for partial breast

Accelerated course Treatment over shorter time course


MODALITIES:External Beam Photons Electrons Protons

Brachytherapy Radioactive source Device

Intraoperative Various means


TECHNIQUES: Positioning Supine vs Prone

CT simulation and volume based planning 3D conformal, e comp, IMRT Respiratory control with deep inspiration breath hold technique “respiratory gating”


How is treatment tailored to the individual patient?

Patient factors Treatment factors Disease burden Biology Risks for disease morbidity vs treatment morbidity


Patient factors: age, comorbidities Treatment factors: type and extent of surgery, type of

systemic therapy, response to neoadjuvant therapy Disease burden: T stage / size, N stage / # / ratio, ECE,

LVSI, EIC, margins Biology: grade, ER, PR, Her2, gene profile


POSITIONING OPTIONS:

Respiratory gating cube and glasses

Prone breast board

USE OF “RESPIRATORY GATING”

Free Breathing

Breath Hold

RATIONALE FOR PRONE POSITIONING

Prone position used for stereotactic core biopsy and breast MRI

Technique adopted and modified for radiation treatment delivery

Displacement of breast tissue away from chest wall and torso

Minimize acute and late skin effects Minimize skin folds Particularly in women in large pendulous breasts High BMI/obesity

Minimize dose to normal tissues Lung Heart Medical co-morbidities: underlying pulmonary disease

(COPD, smoker), cardiac disease, collagen vascular disease, prior RT

RATIONALE FOR PRONE POSITIONING

Select patients with early stage disease

Breast is target

Minimize normal tissue doses and treatment toxicity

USE OF PRONE POSITIONING

MSKCC, USC, NYU, MCW, OSU, and others

Whole breast Partial breast Concomitant boost Ongoing investigations for nodal regions, extended fields

Lower lung doses Often lower heart doses Less skin toxicity No increased recurrences Reproducibil ity

EARLY EXPERIENCES WITH PRONE

Thoughts on implementing prone positioning

Important to have as an option for breast cancer treatment to minimize toxicity

TEAM approach

Requires active physician involvement and engagement throughout care (clinic, simulation, planning, verification, treatment)

Learning curve

THOUGHTS ON PRONE POSITIONING

Definitions: Breast contour: Clinical breast tissue Includes lumpectomy CTV Excludes pectoralis muscles,

chest wall, ribs Chest wall contour: From skin to rib/pleural

interface Includes pectoralis muscles,

chest wall, ribs Breast + chest wall: For more locally advanced

/ high risk patients Regional nodal volumes

RTOG CONTOURING ATLAS

White et al, RTOG Breast Cancer Contouring

BREAST CONTOUR

REGIONAL NODAL VOLUMES CONTOURS

Other considerations: CTV Location Inner quadrants, particularly upper inner, can be challenging Anterior/skin extent Posterior extent of disease and proximity to chest wall/pectoralis

muscles

Select patients with early stage disease

Breast is target

Minimize normal tissue doses and treatment toxicity

PATIENT SELECTION FOR PRONE

Early stage diseaseStage 0, I, II

Following breast conserving surgery

Target = breast tissue not chest wall not lymph nodes not post-mastectomy


LIMITED NODAL COVERAGE WITH TANGENTS IN PRONE POSITION

Csenka et al, Therapeutics and Clinical Risk Management 2014

LIMITED NODAL COVERAGE WITH TANGENTS IN PRONE POSITION

Leonard et al, Radiation Oncology 2012

REVIEW OF BREAST MRI CAN BE HELPFUL

Need to be able to get into the prone position and maintain stable position Arm and neck range of motion Back pain Agility and flexibility Body habitus Respiratory status Performance status Asking the patient about she tolerated prior biopsy procedure and /

or MRI can be helpful


Physician presence to check set up wires, marks, positioning and reproducibility, anticipated tangent fields and heart and lung dose

ASSESSMENT AT SIMULATION

OPTIONS TO MINIMIZE CARDIAC DOSE

Beck et al, Frontiers in Oncology 2014

POSITIONING AND HEART LOCATION

Huppert et al, Frontiers in Oncology 2011

ClearVue Prone Breast Board Indexed to CT-Sim

couch and Linaccouch Interchangeable for

right and left breasts

CT-SIM SETUP

Inser t Opt ions and Dimensions

CT-SIM SETUP

Limited to 18cm of space between surface and base

Rulers Vertical Horizontal

CT-SIM SETUP

Step stoolPatient push-ups Sheet sizePillow casesKeep horizontal ruler

set

CT-SIM SETUP

WiresLumpectomy scarNodal scarMidlineEdge of both breast

tissueBorders of breast

tissue (2 cm margin)

CT-SIM SETUP

Head turned toward ipsilateral side Creates a tripod

position(minimize rotation) Body NOT rotated into

opening Arms above head holding

bars Knee roll cushion under

ankles Patient moves so ML wire is

palpable and visible in cutout opening

Swipe contralateral breast out

Keep couch lateral at 0

CT-SIM SETUP

Table is as low as possible Includes entire body

contour

SUP/INF position of breast centered in cutoutCT angle of

mandible to L3

CT-SIM SETUP

CT-SIM SETUP

5 Tattoos 1 on breast Mid nipple Relatively flat

4 on back Lower straightening about 15-20cm inf the upper

tattoo Avoid pants

Laser at 0 Not necessarily midline

Landmarks Most inf crease of neck Record rulers Vertical Horizontal

CT-SIM SETUP

Breast tattooToo small not enough surface area

Too irregular No stable area to place

tattoo

May have to put tattoo more posterior

SETUP CHALLENGES

Breast hang is more than 18cmUse styrofoamBreast “puddles” on

styrofoam

SETUP UP CHALLENGES

Moving patients on the prone board Transfer sheets

Patients rolling into cutout

Neck pain Use cushion under head Patient movement to

readjust Tried using warm rice

bags

SETUP CHALLENGES

Wire contralateral breast with double solder wire Documents edge of

treatment field

Image all fieldsDaily PF for 1st

week of treatment

VERIFICATION DAY

TREATMENT SETUP

Set table Couch lateral to zero Set horizontal ruler

Patient moves into settings

Swipe contralateral breast

TriangulateFeel for sternumBar pushed in so not

treated through

TREATMENT SETUP

Table raised to breast tattooGantry rotated to

lateral referenceSet SSD on breast

tattooRotate gantry to

lateral treatment field check treatment SSD

TREATMENT SETUP

BBS + USER ORIGIN

DAILY TX ISO SHIFT

TX FIELDS

TX FIELDS ON SKIN

TREATMENT FIELDS

NORM POINT AND DOSE

ORTHOGS

MOSAIQ

Dosimetric Comparison of 3D-CRT, ECOMP, and Hybrid IMRT Plans for Prone Whole Breast Irradiation

Haley Lowe, BA, Rachel Hackett C.M.D., Ir is Wang Ph.D, Kil ian Salerno M.D.R o s w e l l P a r k C a n c e r I n s t i t u te | B u f f a l o , N e w Y o r k

3D-CRT, ECOMP, AND HYBRID IMRT

• 20 patients post breast conservation surgery simulated in the prone position on a specialized prone breast board (10 right sided, 10 left sided)

• Dose prescription: 40 Gy in 15 fractions

• 3 treatment plans per patient were designed using Varian Eclipse 11 to treat the whole breast to the 95% isodose line

• Plans were tradit ional 3D-CRT plan using wedges, ECOMP plan, and Hybrid IMRT—where 2/3 of the dai ly dose is del ivered with 3D-CRT and remaining 1/3 dose with forward planned IMRT

• Use of prone posit ion for whole breast radiotherapy may achieve a significant reduction in lung and heart radiation dose when compared to tradit ional treatment in the supine posit ion.

• Treatment del ivery with ECOMP or a hybrid IMRT technique can fur ther reduce heart and lung dose compared to 3D-CRT with wedges.

• Hybrid IMRT provides a significant reduction in maximum breast dose.

• ECOMP al lows for the maximum decreases in mean heart dose while maintaining a relatively low maximum dose.


Evaluation and dosimetric comparison of V20, heart dose and maximum dose for dif ferent prone whole breast irradiation planning techniques including 3D-CRT, ECOMP and hybrid IMRT.


• Global maximum dose for al l patients was reduced while maintaining dose homogeneity using both ECOMP and hybrid IMRT when compared to 3D-CRT. Maximum dose reduction using hybrid IMRT averaged a 1 .3 Gy dose reduction compared to 3D-CRT planning.

• No dif ference in ipsi lateral lung V20 was seen between the dif ferent planning techniques.

• Mean heart dose was reduced in the ECOMP and hybrid IMRT plans compared to the 3D-CRT plans. Hybrid IMRT reduced mean heart dose by 0.7 Gyfor the right breast, 0.9 Gyfor the lef t; ECOMP reduced mean heart dose by 2.2 Gyfor the right, and 2.9 Gy for the lef t.

• There was no correlation found between the breast volume and maximum dose, ipsi lateral lung V20, or mean heart dose.


IRREGULAR SURFACE COMPENSATORS

INHOMOGENEITY CORRECTION ON: OPT + CALC

EDIT FLUENCE - MAKE IT FLASHY

RESULT OF DOSE CALCULATION

LACK OF TANGENTIAL DOSE

PRESCRIBE DOWN –“PAINT” OUT THE HOT

HEART DOSE

HEART AVOIDANCE

LUNG DOSE REDUCED – A LOT

Kilian Salerno, MD Simon Fung-Kee-Fung, MD Maria Durlak, RTT

THANK YOU!