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Year : 2018  |  Volume : 14  |  Issue : 11  |  Page : 823-832

Breast Oncology

Date of Web Publication29-Nov-2018

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How to cite this article:
. Breast Oncology. J Can Res Ther 2018;14, Suppl S4:823-32

How to cite this URL:
. Breast Oncology. J Can Res Ther [serial online] 2018 [cited 2019 Oct 20];14:823-32. Available from: http://www.cancerjournal.net/text.asp?2018/14/11/823/246373

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Dosimetric comparison of two planning techniques for chest wall irradiation

Shalu Verma, Virendra Bhandari, O. P. Gurjar, Priyusha Bagdare, Sumit Gupta

Aim: To compare the field-in-field (FIF) planning technique with the intensity modulated radiotherapy (IMRT) planning Technique. Materials and Methods: Twenty patients with carcinoma breast were simulated with immobilization devices viz. breast board and thermoplastic sheet. Computed tomography (CT) was done for all the patients and CT images with 3mm slice thickness were acquired. The images were transferred to the treatment planning system (TPS). Target and organs at risk (OAR) were delineated and then FIF and IMRT plans were generated for 50Gray (Gy) in 25 fractions (#) following Radiation Therapy Oncology Group (RTOG) guidelines. Both kind of plans were analyzed and compared based on dosimetric parameters. Results: The mean dose to 95% (D95%) of PTV was 95.64% (±0.48%) and 96.23% (±1.33) in left sided and 94.51% (±2.38) and 95.14 (±0.79) in right sided patients in FIF and IMRT plans respectively. The mean maximum dose (Dmax)to spine was 16.65 Gy (±24.9%) and 18.82 Gy (±14.5) in left sided and 28.76 Gy (±16.7) and 21.7 Gy (±13.6) in right sided patients in FIF and IMRT plans respectively. The volume receiving 20 Gy (V20) of ipsilateral lung was 23.73% (±6.26) and 24.86% (±1.05) in left sided while 28.8% (±2.72) and 21.98% (±10.98) in right sided in FIF and IMRT plans respectively. The volume receiving 40 Gy (V40) of ipsilateral lung was 17.05% (±3.98) and 4.23% (±1.01) in left sided while 20.66% (±8.55) and 5.4% (±1.31) in right sided in FIF and IMRT plans respectively. The mean dose (Dmean) to contralateral lung was 1.09 Gy (±0.73) and 5.68 Gy (±0.34) in left sided while 0.94 Gy (±0.89) and 5.1 Gy (±1.22) in right sided in FIF and IMRT plans respectively. The mean dose (Dmean) to heart was 10.66 Gy (±1.84) and 12.68 Gy (±0.92) in left sided while 2.22 Gy (±1.39) and 8.65 Gy (±1.26) in right sided in FIF and IMRT plans respectively. Conclusions: The target coverage is almost similar in both plans while doses to OAR like heart and contralateral lung in FIF plans are very less in comparison with that in IMRT plans as well as total integral doseis much less in FIF plans. Seeing the chestwall movement it can be concluded that the FIF planning technique should be preferred.

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Forward intensity modulated radiotherapy versus inverse intensity modulated radiotherapy in left sided breast cancer patients: A dosimetric comparison

Yamini Bachheti, Vipul Nautiyal, Meenu Gupta, Rishabh Dobhal, Ravi Kant, Saurabh Bansal, Meenu Gupta

Aims/Objectives: To evaluate the dose distribution of forward intensity modulated radiotherapy (IMRT) compared to inverse-IMRT in left sided breast cancer patients. Materials and Methods: For 15 left sided breast cancer patients' f-IMRT and inv-IMRT plans were generated. The prescribed dose was 45 Gy in 20 fractions as per our institutional protocol. Dose-volume histograms were evaluated for the PTV and organs at risk. The homogeneity of dose to planning target volume (PTV) and the dose delivered to lung, heart and contralateral breast were compared between the two techniques in all the 15 patients. Parameters of the dose distribution were compared using the pair-t-test. Results: After the evaluation of the planning, it was observed that for f-IMRT technique as compared to inv-IMRT. The low dose volumes (V5Gy) in heart and lung were higher in inv-IMRT (86.49 Vs 52.39) and (64.1 vs. 20.6) respectively. Mean dose to contralateral breast was also slightly higher for inv-IMRT than f-IMRT plans (4.2 vs. 2.8). There was no significant difference in V20Gy to ipsilateral lung and mean dose to heart in both arms The inv-IMRT plans had significantly better conformity index (CI) (0.94 vs. 0.75 p=0.000) and Homogeneity index (HI) (0.25 vs. 0.15 p=0.006). Conclusion: Inv-IMRT demonstrated a significantly better conformity and homogeneity index for the PTV without significant difference in doses to organ at risk in left breast cancer patients but patients with Inv-IMRT had significantly higher low doses volume in ipsilateral lung, c/l breast and heart.

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Comparative analysis between anthracycline based regimen and platin based regimen in neoadjuvant setting for triple-negative breast cancer: A single institutional retrospective study

Satadru Biswas, Ritam Joarder, Krishnangshu Bhanja Choudhury

Objectives: Considering neoadjuvant chemotherapy (NACT) a new horizon for exploration in Triple Negative Breast Cancer (TNBC) this study was designed to comparatively analyse the response and survival between a platin-based and an anthracycline-based combination chemotherapy regimens. However, the comparison between Carboplatin plus Paclitaxel (TP) vs. 5FU plus Epirubicin plus Cyclophosphamide (FEC) was done not only in TNBC patients of locally advanced breast cancer (LABC) and large operable breast cancer (LOBC) but also in selected early breast cancer (EBC) patients as NACT. Materials and Methods: In this single institutional retrospective study total 73 consecutive patients registered between January, 2014 and December, 2016 in our out-patient department, with tru-cut biopsy confirmed pathological diagnosis of invasive breast cancer clinically, AJCC stage IIB ∼ IIIB, negative for estrogen and progesterone receptors and HER2 by immunohistochemistry, were included. After baseline staging mammogram and other metastatic work up patients received 6 cycles of either Paclitaxel 175 mg/m2 and Carboplatin at an AUC 5 iv on day1, every 21 days or 5FU 500 mg/m2, Epirubicin100 mg/m2, Cyclophosphamide 500mg/m2 iv on day1. Response was assessed after initial three cycles and again after completion of all 6 cycles abide by RECIST v1.1. Modified radical mastectomy (MRM) and adjuvant Radiation Therapy (RT) with 50Gy in conventional fractionation were given if and when indicated. Survival benefits were comparatively analysed in terms of median progression free survival (mPFS). Results: Records were analysed of total 73 TNBC patients up to last follow-up (median follow-up 40 months) among whom 37 received FEC and 36 received TP. Median age of patients receiving FEC and TP were 49 and 53 respectively while parity, menopausal status and number of first and second degree relatives affected were comparable for both arms. Out of 37 patients who received FEC further stratified into 3 EBC, 11 LOBC and 23 LABC and out of 36 patients of TP arm 2, 13 and 21 were EBC, LOBC and LABC respectively. Modified Nottingham Prognostic Index (NPI) score was 2 for majority of patients i.e. 64.9% in FEC and 61.1% in TP arm. MRM and adjuvant RT could be given with radical curative intent in 62.2% & 86.1% patients of FEC and TP arms respectively (p value 0.020) while rest were treated with palliative intent due to disease progression. Post- NACT pathological T0 (ypT0) was achieved in 13.5% & 41.7% patients of FEC and TP arms respectively (p value 0.007). Complete response (CR) and partial response (PR) were achieved in 13.5% and 43.2% (FEC arm) vs. 33.3% and 63.9% (TP arm); p value 0.001. mPFS was 13 months vs. 17 months (p value 0.001). No significant difference in both arms in terms of severe haematological toxicities was found (29% Vs 33%, p=0.61) though neurological toxicities were slightly more common in TP arm. Conclusion: Platin-taxane combination chemotherapy was proven promising over anthracycline-based combination chemotherapy in neo-adjuvant setting while treating TNBC of various stages in terms of efficacy with tolerable toxicity profile.

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An interim analysis of prospective study to compare heart doses for left sided breast or chest wall radiotherapy using conventional and deep inspiratory breath hold technique in breast carcinoma (DIBH study)

Soujanya Ferdinand, Abhijit Basu, Suman Mallik, Jyotirup Goswami, Sayan Das, Monidipa Mondal, Arijit Sen, Bipasha Pal, Suresh Das, Soura Palit, Papai Sarkar, Shubhayun Mondal

Narayana Superspeciality Hospital, Howrah, West Bengal, India

Objectives: The risk of radiation therapy (RT)-associated cardiovascular disease in long term survivors of breast cancer has been a concern for decades. The objective of our study is to compare dose to heart and Left Anterior Descending (LAD) artery using conventional and DIBH techniques in left sided breast carcinoma. Materials and Methods: We have accrued 31 consecutive left sided breast cancer patients and analysed 30 observations of 15 patients till now (that includes difference in doses to heart and LAD in conventional versus DIBH technique in left sided breast carcinoma receiving radiation to breast/chest wall). Out of these fifteen patients, seven underwent Modified Radical Mastectomy (MRM) and Breast Conservative Surgery (BCS) was done for the remaining eight. Pre-radiotherapy planning CT scans were done in free breathing and in deep inspiratory breath hold position using active breathing coordinator system with prior counselling on breath hold technique. Patients received 40 Gy in 15 fractions over 3 weeks for whole breast/ chest wall irradiation and a tumour bed boost dose of 12.5 Gy in 5 fractions over 1 week for patients undergoing BCS. 3DCRT plans were generated for both scans followed by comparison of anatomical and dosimetric variables using paired t test with IBM SPSS software version 22. Results: Regarding the anatomical parameters, DIBH plans increased lung volume (2325.7 vs 3410.7 cc, p < 0.0001), chest depth(19.5 vs 20.2 cm, p<0.0001), lung orthogonal distance(2.5 vs 2.9 cm, p<0.05) and decreased maximum heart depth(2.1 vs 1.3 cm, p<0.01) and heart chest wall length (6.7 vs 6.0, p<0.001). Considering dosimetric variations DIBH plans decreased mean heart dose (4.8 vs 2.4 Gy, p<0.001), V30 of heart (4.9 vs 0.3, p<0.001), V5 of heart (16.2 vs 7.8%, p< 0.002), V10 of heart (11.6 vs 3.3 %, p< 0.001), max dose to left anterior descending artery (LAD)(35.9 vs 25.6 Gy, p<0.0001), lung V20 (11.1 vs 9.2%, p<0.06), lung V12 (13.4 vs 12.0%, p<0.19) and ipsilateral lung V20 (23.0 vs 19.3%, p<0.08). Conclusion: Interim analysis showed considerable reduction in heart and LAD doses using DIBH technique compared to non DIBH technique in left sided breast carcinoma. Further analysis is needed to identify anatomical and treatment parameters that correlate with cardiac sparing in DIBH technique.

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A retrospective epidemiological study on the pattern of distribution of ER/PR/HER 2-neu/Ki-67 status among patients of carcinoma of breast, in a tertiary care level hospital of West Bengal, India

Arindam Chaudhury, Biswamit Bhattacharya, Diptimoy Das, Sanatan Banerjee

Department of Radiotherapy, Burdwan Medical College and Hospital, Bardhaman, West Bengal, India

Background: Carcinoma of breast is one of the predominant causes of cancer related mortality in women. Though commoner in urban parts of India, especially among the affluent society adopting westernized lifestyle, breast cancer is also becoming increasingly prevalent among rural women and women belonging to the underprivileged sections of the society. Epidemiologic data regarding different phenotypic subgroups in Indian women is scarce and more so for rural scenario. Aim: Our aim was to find out the epidemiological distribution of different phenotypic subgroups in the patients suffering from carcinoma of breast, who attended the Outpatient Department of Radiation Oncology, Burdwan Medical College and Hospital, which predominantly caters to the rural population of the Southern districts of West Bengal. We also aim to find out any difference of disease biology and its epidemiologic distribution in our rural population, with that of the international data. Methods: This is a retrospective, observational, descriptive, single-institutional epidemiological study from pre-recorded hospital data. Cases of Carcinoma of breast attending the Radiation Oncology outpatient department of Burdwan Medical College and Hospital, during the last five years (June 2013 – May 2018) were selected for this study. Hospital recorded data was taken and analyzed regarding the age of presentation, menopausal status, stage at presentation, histopathological subtypes, tumour grade, hormone receptor (ER/PR) expression status, HER 2-neu expression status, Ki-67 status, and their phenotypic subgroup classification. Results: Among the 416 patients enrolled for this study 35.8% were premenopausal while 64.2% were postmenopausal with 93.9% of them being of the infiltrating ductal carcinoma variety. Histopathological grade wise, majority of the patients were of Grade III (53.61%) variety and 69.9% of the total number of patients had a high Ki-67 score. Majority of the patients enrolled had presented in the locally advanced stage (59.6%). The phenotypic subgroup classification of the enrolled patients were as follows: Luminal A – 29.1%; Luminal B – 31.7%; TNBC – 26.9%; HER 2-neu overexpressing – 12.3%. In subgroup analysis, we found that in premenopausal subgroup, incidence of Luminal B were higher at 42.9%, followed by TNBC at 29.5%, and that of Luminal A disease was low at 22.2%; 77.9% of this subgroup had high Ki-67 score. In the postmenopausal subgroup, Luminal A was the most predominant subtype (32.9%), and 53.9% of the patients were ER positive. Conclusion: It is concluded from the current study that the Luminal A was the most prevalent subtype in postmenopausal patients of carcinoma of breast while Luminal B was the commonest variety, followed by triple negative carcinoma of breast, in younger premenopausal women and highly aggressive tumours with high Ki-67 score were also commoner in this group. The prevalence of triple negative carcinoma of breast in Indian women is comparable with their western counterparts. Further multi-centric studies involving greater number of patients are required to confirm the results.

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Comparison of clinical outcomes of adjuvant chest wall with or without regional irradiation in 549 women of breast cancer treated with different fractionation schedules over 2 years

Niranjan Kumar Dash, A. Budrukkar, T. Wadasadawalla, R. Jalali, R. Upreti, V. Parmar, S. Gupta, R. Badwe, R. Sarin

Aims/Objectives: Hypofractionated radiation therapy has been well established as the standard of care in early breast cancer in patients those who underwent breast conservation surgery. But there is lack of general consensus regarding the use of hypofractionation schedule in locally advanced breast cancer and those who have undergone mastectomy either upfront or after neoadjuvant chemotherapy. The aim of this study was to evaluate the clinical outcomes of moderate hypofractionated post mastectomy radiotherapy (PMRT) as compared to mild hypo-PMRT in patients who underwent mastectomy either upfront or after neoadjuvant chemotherapy. Materials and Methods: Five hundred seventy seven female breast cancer patients with histological proven invasive breast cancer and who were treated with mastectomy, chemotherapy and adjuvant postoperative radiotherapy at TMH from Jan 2013 to Dec 2014 were included in this study. Patients with previous history of irradiation, histology suggestive of Phylloid tumor, Sarcoma and recurrent patients were excluded. After excluding 28 patients as per exclusion criteria, 549 patients were analysed. In the year 2013-patients were treated with mild hypo-PMRT (45 Gy in 20 fractions at 225 cGy per fraction) and in 2014- patients were treated with mod hypo-PMRT (40 Gy in 15 fractions at 267 cGy per fraction) all were delivered with 5 fractions a week schedule. Same fractionation schedule was used for regional nodal irradiation when indicated. Results: Median follow up for the entire cohort was 38 months. Clinicopathological characteristics were comparable between the two groups. Median age was 50 year (Range25- 82 years). Median clinical tumor size at presentation was 5 cm. Median pathological tumor size was 3.5 cm. At 4 year the local control was 91.1% and 90.6% (p=0.494), locoregional control was 83.1% and 84.2% (p=0.636), Disease free survival (DFS) was 55.7% and 62.1% (p=0.59), and overall survival (OAS) was 87.4% and 93.5 % (p=0.051) in mild and moderate hypo-PMRT arm respectively. On univariate analysis there was no significant difference in clinical outcomes in different prognostic factors like node positive, hormone receptor negative, IDC grade 3 and presence of LVE. Conclusion: Moderate Hypo-PMRT is safe and effective in terms of clinical outcomes and should be encouraged to be used in developing countries like India due to resource sparing potential and giving logistic benefit both to the patients and health care provider. Presence of node positive disease, IDC grade 3, hormone receptor negative disease and presence of LVE should not be a contraindication for use of Mod- hypo PMRT.

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Radiation exposure to heart in left sided whole breast radiation: Dosimetric estimates with three dimensional conformal radiation with tangential fields

Ritesh Kumar, P. Manasa, A. Binjola, B. Krishnan, R. Biswas

Department of Radiotherapy, All India Institute of Medical Sciences, New Delhi, India

Background/Objective: Whole Breast Radiation (WBRT) is indicated in the management of Early Breast Cancer (EBC) as a component of multimodality management after Breast Conserving Surgery (BCS) and Chemotherapy. Heart receives a significant radiation (RT) doses in left sided WBRT, which results in long term cardiac morbidity and mortality. This study was done to estimate the RT exposure to the heart in Left sided breast cancer when planned with Three Dimensional Conformal Radiation (3DCRT) with tangential fields for WBRT alone. Methods: Radiotherapy Planning CT scan of fifteen patients of Left sided Breast cancer post BCS and chemotherapy were reviewed for this dosimetric study. All the patients were planned with WBRT alone with 3DCRT technique with tangential fields and wedges. Planning CT was done with patients in supine position in breast board with both arms above head. The Clinical Target Volume (CTV) comprised whole breast and organs at risk (OAR) contoured were heart, ipsilateral lung, contralateral lung and contralateral breast. Contouring was done as per the standard RTOG guidelines. Planning target volume (PTV) was generated with 1 cm isotropic margin. PTV_EVAL was generated for dosimetric evaluation with PTV trimmed 5mm below the skin. Planning was done with 3DCRT technique using two tangential fields with wedges. The dose prescribed was 50 Gy in 25 fractions over 5 weeks. Contouring and planning was done on MONACO treatment planning system. Results: Plans were optimized for the best PTV coverage, dose homogeneity and OAR sparing. The PTV_EVAL coverage with 95% isodose line (IDL) ranged from 95.3% to 98.5% (mean – 96.6%) with PTV_EVAL receiving more than 110% IDL ranged from 0.0% to 6.9% (mean – 3.1%). On estimation of cardiac doses,, the V25 Gy for heart ranged from 7.18% to 15.7% (Mean – 11.6%). The Mean heart dose ranged from 4.56 Gy to 11.32 Gy (Mean – 8.48 Gy). The V20 Gy and V5 Gy for ipsilateral lung ranged from 14.6% to 18.9% and 33.7% to 40.2% respectively. The mean contralateral lung dose ranged from 0.42 Gy to 0.76 Gy. Mean Contralateral Breast dose ranged from 0.62 Gy to 1.56 Gy. Conclusions: WBRT in Left sided breast cancer is associated with significant RT doses to the heart. With the present evidence, this RT dose to heart can lead to long term cardiac morbidity and mortality. Thus, the treatment planning and evaluation of WBRT in left sided breast cancer should be done to minimize the radiation exposure to heart to decrease long term cardiac toxicity.

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Vitamin D and its association with breast cancer

Shailley Arora Sehgal, Anil Khurana, Anil K. Dhull, Paramjeet Kaur, Ashok Chauhan, Vivek Kaushal

Department of Radiation Oncology, Pt. BDS Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Aim: To evaluate the difference between serum 25 hydroxy vitamin D [25(OH) D] levels amongst breast cancer patients and age matched healthy controls and evaluates the association of vitamin D levels with breast cancer risk. Methods: From Jan 2015 to June 2016, we enrolled 40 histopathologically confirmed breast cancer patients and compared with age matched 40 healthy controls. In all the patients, serum 25(OH) D Level were measured using Radioimmunoassay method (Bechman Coulter) and recorded in ng/ml. Vitamin D deficiency was defined as per the United States Endocrine Society guidelines (Vitamin D insufficiency as 20 to 30 ng/mL and deficiency as levels less than 20 ng/mL). Results: Mean age was 46 ± 8-years for breast cancer group and 40 ± 9 years for controls. A significant association (p value 0.033) was found between low serum 25 hydroxy vitamin D levels andNN the risk of carcinoma breast with adjusted odds ratio 95% CI of 2.654 (1.074-6.557). 27-patients amongst breast cancer group were vitamin D deficient (<20ng/ml) as compared to 18 amongst controls. There were 13 breast cancer patients and 15 controls falls under insufficient vitamin D category. However, there was no patient which has sufficient vitamin D but 7-controls falls under this group. Conclusion: We conclude that vitamin D deficiency is closely associated with breast cancer and these patients are more likely to be vitamin D deficient, however, vitamin D supplementation will help reducing the risk in healthy subject is still an unanswered question which requires further randomized controlled trials.

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Hybrid intensity modulated radiation therapy for treatment of cancer of left breast after mastectomy

Shruti Maheshwari, Mahesh Upasani, Prashantkumar Shinde, Rameshwar Veer, Sameer Chandorkar, Rahul Patil, Manish Mathankar, Alok Chand, Hemant Ghare, Parimal Patwe, Mukesh Meshram

Department of Radiation Oncology, National Cancer Institute, Nagpur, Maharashtra, India

Purpose/Objective: Evaluation of hybrid intensity modulated radiation therapy technique for treatment of chest wall and supraclavicular nodal irradiation in cancer of left breast after mastectomy. Materials and Methods: This retrospective dosimetric study included fifteen patients of carcinoma of left breast who were referred for adjuvant radiotherapy, after mastectomy. We compared the standard field in field forward planning radiation therapy (FIF) technique with a novel technique of hybrid planning where we used combination of inverse planning IMRT with standard field in field (Hybrid IMRT) technique for chest wall. Patients were treated with the standard field in field forward planning radiotherapy (FIF) technique. Dose–volume histograms were calculated for the planning target volume (PTV), volume that receives 90% of the prescribed dose (PTV90%); heart; and the left lung. Various dosimetric parameters like conformity index, CI; for left and right lung (left lung mean, V5, V10, V16, V20 and right lung mean) and for heart (mean, V5, V10, V25, V30) of both plans were compared for evaluation. Results: Hybrid IMRT plans had significantly smaller heart volumes with higher doses than standard FIF plans. Heart V30Gy (4.6% vs 12.4%, p<0.0001) was significantly better with hybrid IMRT. Heart V25Gy (10.1% vs 14.4%), left lung mean dose (10.3Gy vs 10.7Gy) and left lung V20Gy (8.3% vs 8.7%) was better with Hybrid IMRT. Both hybrid IMRT and standard FIF achieved similar PTV90% coverage (91.6% vs 91.4%) and conformity (0.92 vs 0.91). Right breast mean doses were <2.3Gy for all. Conclusions: Hybrid IMRT achieves equal coverage for the target volume while significantly reducing high dose heart volumes as compared to standard FIF. Hybrid IMRT is a feasible option for treatment of left sided chest wall. This technique needs to be evaluated further in prospective setting for further validation and appropriate case selection.
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Volumetric estimation of lung dose and its association with pneumonitis following postmastectomy radiotherapy using two-dimensional tangential techniques in breast cancer patients

M. Geetha, N. V. Vinin, Joneetha Jones, E. S. Arunkumar, C. A. Suja, Anjana

Aims and Objectives: To estimate the lung dose volumetrically and its association with radiation pneumonitis in breast cancer patients treated with radiotherapy using 2D tangential techniques. Methods: Patients treated with post-mastectomy radiotherapy with conventional 2D technique using medial tangential (MT) and lateral tangential (LT) fields were studied retrospectively. The data of patients planned on CT simulator was transferred to the treatment planning system (TPS) and the target volumes and organs at risk were contoured. Treatment planning was done with the same number of fields and beam arrangement, isocentre and field sizes. The dose delivered was 40 Gy in 15 fractions. Central Lung Distance (CLD) was measured from the CT simulator and Volume of lung receiving 20 Gy (V20) and mean lung dose (MLD) from the TPS. V20 for MT, LT and SCF was measured. V20 for same patients excluding SCF fields was also measured. The correlation between CLD and V 20 with MT and LT fields and MT, LT and SCF fields were analyzed. Comparison of V20 for MT and LT and MT, LT and SCF fields was also done. Correlation between CLD and MLD was done. The incidence of radiation pneumonitis and its association with lung dose also were studied in this group of patients was also studied. Results: Total 50 patients were studied. with median age 52 years. 48 patients were treated with three fields (MT, LT and SCF) and 2 patients were treated with two fields (MT & LT). Majority had diabetes mellitus (44%) and stage III disease (64%). 86% of patients received chemotherapy with 4 cycles of Adriamycin and Cyclophosphamide followed by weekly paclitaxel for 12 weeks. The mean CLD was 2.28 cm and Mean of MLD was 14 Gy. The mean V20 for MT and LT alone was 17 Gy and for MT, LT and SCF was 28 Gy suggesting that there is a significant contribution to the lung dose from Supraclavicular field. Comparison between V20 for MT and LT and MT, LT and SCF was done and was found to be significant. Correlation between CLD and V20 for MT and LT fields as well as MT, LT and SCF field was done and was found to be significant. MLD did not have any correlation with CLD. 3 patients (6%) had radiation pneumonitis. Radiation pneumonitis was not found to have correlation with V20 or MLD in our cohort of patients. Conclusion: Radiation treatment for breast cancers is traditionally being done with conventional tangential beams. It is still an option in countries like India with resource constraints. The incidence of radiation induced lung injury can be minimized in this setting by carefully selecting the beam angles and minimizing the lung volume in the field. Also judicious planning of supraclavicular field will help to reduce the dose to the lung.

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Comparison of sequential and simultaneous integrated boost hypofractionated radiotherapy in patients with breast cancer

Shipra Gupta

Aims: To compare dosimetric parameters, toxicities, cosmetic effects and early clinical outcomes of hypofractionated simultaneous integrated boost (SIB) versus sequential boost (SEQ) with Volumetric Modulated Arc Therapy (VMAT) with hypofractionation after breast-conserving surgery (BCS) in patients with breast cancer. Materials and Methods: A total of 55 breast cancer patients post BCS were enrolled in this CTRI registered (CTRI/2018/04/01300) phase II study. Patients were randomized between two arms, 35 patients in SIB and 20 patients in SEQ arm. For SIB, the dose prescribed to PTV breast was 34Gy/10#/2weeks and 40Gy/10#/2 weeks to PTV boost. For SEQ, dose was 34Gy/10#/2weeks to PTV breast followed by 8Gy/2#/2days to PTV boost. Dose constraints used for both arms varied according to the laterality. Dosimetric data, acute and late toxicities were compared in both arms. Clinical evaluation and photographic evidences were used as subjective and objective criteria, respectively for cosmetic assessment at every follow up till one year. For categorical variables comparison between two arms, chi-square/fisher exact test was used. Mcnemar test was applied to find out any change of outcome variable within the arm. Two tailed p value < 0.05 with 95% CI was considered statistically significant. Results: Mean target coverage was the same for both techniques, 0.94 in SIB arm and 0.97 in SEQ arm. Mean homogeneity index (HI) of PTV volume was better for SIB arm, 0.2 vs 0.3 in SEQ arm (p = 0.03). Dose constraints achieved were significantly better in SIB arm, 42.9% in SIB arm vs 5% in SEQ arm for esophagus (p= 0.003) and 77.1% in SIB arm vs 50% in SEQ arm for contralateral lung (p= 0.003). The mean dose to the contralateral lung was 7.8Gy in the SIB arm as compared to 10.3Gy in SEQ arm (p=0.042). Mean does to the LAD achieved was comparable in both the arms (~5.7Gy). Acute grade 2 dermatitis was noticed in 14.3% in SIB arm and 5% in SEQ arm at 1 month post treatment. Grade 3 dermatitis developed only in SIB arm, 8.6% at 1month post treatment. Acute dermatitis was significantly higher in patients with regional nodal irradiation (p value= 0.001). Hyperpigmentation was comparable in both arms. Skin discoloration and breast pain was significantly correlated with target PTV volume of >1500cc (p = 0.05). Excellent/good cosmesis at baseline and one year was present in 97.1% vs 96% and 95% vs 92.3% patients in SIB and SEQ arm. No pulmonary, cardiological toxicities or brachial plexopathy were recorded. At a median followup of one year, the clinical outcomes were, two cases of distant metastasis in SIB arm and no case of local recurrence in any arm. Conclusions: The 2-week VMAT-hypofractionated RT after BCS was well tolerated, with excellent/good cosmesis in >90% patients and optimal local control in both the arms. However, HI and dose constraints were better achieved in SIB arm.

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Hypofractionationated radiotherapy in breast cancer: Outcome of prospective study done in our institution

Riddhijyoti Talukdar, Litan Naha Biswas, Jibak Bhattacharya, Mukti Mukherjee, Rejil Rajan, Asesh Samanta, Pavitra Vijayaraghavan, Tanweer Shahid

Aims and Objectives: The most common fractionation used for Breast Cancer is conventional (50 Gy in 25 fractions over 5 weeks) followed by boost to the tumour bed for patients undergoing breast conservation. A good number of evidences favour hypofractionation but data on similar practices is still evolving from our country. Breast Cancer contributes to a significant proportion of Radiotherapy patients at most centres. Hypofractionation can be a good option for optimal utilisation of resources. We report the results at our centre with START B type of fractionation. Materials and Methods: From January 2014 to December 2016, non-metastatic breast cancer patients undergoing MRM or BCS were treated using hypofractionated adjuvant radiotherapy. 3DCRT was used to deliver 40Gy in 15 fractions over 3 weeks to the Chest wall or Whole Breast with or without Supraclavicular Fossa (when indicated) for MRM and BCS patients respectively followed by electron boost (12.5 to 15 Gy in 5 to 6 fractions) to the tumour bed in the latter group. RTOG Skin toxicity and cosmesis outcome were assessed during and after completion of Radiotherapy and at subsequent follow-up visits. Cosmesis outcome was assessed by Havard Scale. Recurrences and deaths were also documented, and preliminary survival analysis was done at median follow up. Results: Out of 171 patients, 93 patients underwent BCS and 78 patients had MRM. Mean age of the entire population was 50 years. T2 was the most common tumour stage, (58% and 42% for BCS and MRM group respectively). Invasive Ductal Carcinoma (IDC) was the most common entity seen (90%). The median Nottingham Prognostic Index Score was found to be 4.6 for the BCS as compared to 5.58 for the MRM. Triple Negative Breast Cancer was 28.1% among all patients. 31.2% patients in the BCS group and 44.9% patients in the MRM group received Neoadjuvant Chemotherapy. Grade I Skin toxicity was the most common acute toxicity observed at the end of Radiotherapy, 93.5% in BCS group and 100% in the Mastectomy group. 6 (6.5%) patients in BCS group developed Grade II toxicity at this time. At 3 months, the incidence of Grade I toxicity was reduced to 89.2% and 85.9% for BCS and MRM respectively. At 6 months and 1 year, persistent grade I toxicity was observed in 26.9%, 14% and 15.4%, 9% patients in BCS and MRM group respectively. Excellent and good cosmetic outcome was noted in 66.7% and 32.2% respectively on follow up for BCS group. Median follow up was 15 months. 25 patients (14.6%) developed distant metastasis. At 15 months RFS and OS were 87.2 % and 87.5% respectively. Conclusion: Hypofractioanated Radiotherapy in breast cancer is well tolerated with acceptable skin toxicity and excellent to good cosmetic outcome in Indian population. This strategy can be applied to utilize our resources optimally. This is an on-going study to assess the long term results.

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Factors influencing the development of hypothyroidism following SCF irradiation in carcinoma breast patients

Chinnu Jomi, Jaineet Sachdeva, Pamela Jeyaraj, Anumanth Arputharaj

Aims and Objectives:

To find out the patient related (age, menopausal status, thyroid volume), tumor related (stage, ER/ PgR/ Her2neu) and treatment related (timing of chemotherapy and mode of surgery) factors and the mean time for the development of hypothyroidism in patients who receive postoperative radiation to chest wall/ breast and regional lymph nodes. Materials and Methods: Patients with a histological diagnosis of carcinoma breast who fulfill the inclusion and exclusion criteria underwent planning CECT of neck and chest, target volume and organ at risk were contoured and treatment was started after generating the treatment plan. Baseline thyroid profile was done before starting treatment. All patients received radiation to chest wall and supraclavicular lymph nodes. A total dose of 50Gy in 25 fractions was delivered, with 6 MV Elekta compact LINAC by 3DCRT technique, to both areas. Thyroid gland was contoured on 3 mm thickness CT scans. After treatment thyroid profiles were repeated and the patients were followed up monthly by clinical examination and 3 monthly by thyroid profiles for a minimum of 6 months. Patient, tumor and treatment related factors and mean time for onset of hypothyroidism were evaluated. Results: After a maximum follow up of 21 months, 17% of the patients (0.02% - clinical and 14.3% - subclinical hypothyroidism) developed thyroid function abnormalities. Patients with mean TSH value of 3.5 at 6 months were at increased risk of developing hypothyroidism (p=0.0001). Thyroid volume less than 8 cm3 was found to be a significant predictor for the development of hypothyroidism (p=0.02). However age, menopausal status, tumor stage, receptor status, timing of chemotherapy and mode of surgery did not show any statistical significance. Conclusion: In majority of the node-positive breast cancer patients treated with 3D CRT, the thyroid gland will be exposed to considerable doses. With increasing survival in breast cancer patients, the incidence of radiation induced hypothyroidism is also gaining importance. Guidelines for routine monitoring of thyroid function during follow-up, after breast cancer treatment should be defined for these patients. A larger sample size and longer follow-up will give more conclusive evidence regarding the same.

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Predictors of outcome in breast cancer patients with oligometastases and the appropriate role of radiotherapy

Irfan Ul Huq, N. V. Kalaiyarasi, R. Giridharan, Poonkodi

Madras Medical College, Chennai, Tamil Nadu, India

Aim: To assess the distant progression free and overall survival rate in breast cancer patients with oligometastasis according to receptor status. Materials and Methods: We retrospectively reviewed 150 metastatic breast cancer patient in our institution from JANUARY 1996 to DECEMBER 2012. During that period 61 patient had been diagnosed with oligometastases, following standard treatment for primary breast cancer. We defined oligometastases as metastases at less than or equal to 5 distinct clinical sites. It was determined by imaging and clinical documentation. Patients were assessed with different characteristics such as age, menopausal status, histopathological grading, involved quadrant and side of breast, Axillary lymph node status, body mass index, Bone metastasis, visceral metastasis, hormone receptor status (luminal A, luminal B, HER 2+, basal). Palliative chemotherapy and radiation was used to treat oligometastases. Treatment responses were evaluated according to the Response Evaluation Criteria in Solid Tumours (RECIST) guidelines. Results: The 5 year tumour local control and 3 year distant progression free survival rate was 54% and 29% respectively. High RT dose was significantly associated with improved local control. Patients were assessed with different characteristics such as Age <40 years – 18 patients, >40 years– 43patients, premenopausal women – 36 patients, postmenopausal women – 25 patients, Histopathological Grading (Scarff Bloom Richardson classification) Grade I- 31 patients, Grade II – 18 patients, Grade III – 12 patients, site – Inner Quadrant – 10 patients, Outer Quadrant – 33 patients, Central – 18 patients, Axillary Nodal status – N1- 20 patients, N2- 23 patients, N3- 8 patients, BMI - <18.5- 1 patient, 18.5- 24.9- 13 patients, 25 – 29.9 – 27 patients, >30 – 20 patients. 41 patients had bone metastases, for which 30Gy (3 Gy IN 10 fractions) radiotherapy was given for both spine and other sites. 18 patient had visceral metastases (Lung, Liver, Brain, Lymph node). In that 10 had brain metastases. Whole brain radiotherapy 30 Gy (3 Gy IN 10 fraction) were given. Hormone Receptor status was classified as Luminal A – 33 patients, Luminal B – 7 patients, HER 2+ – 5 patients, Triple Negative (basal) in 16 patients. 5 year Overall Survival rate for hormonal receptor status was 40%, 4%, and 1.6%, 3.2% respectively. Conclusion: This study showed that, after aggressive treatment of oligometastatic breast cancer, patients had an improved 5 year Survival rate with luminal A than other receptor status and distant progression free survival.

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Variation in pulmonary function in carcinoma breast patients receiving radiation therapy

N. P. Jayashree, C. K. Fareena Taj, Ibrahim Khaleel, Shija Merin, Harshitha, Niveditha Sarkar, H. B. Govardhan

Introduction: To compare two fractionation schedules i.e, conventional (CF) and hypofractionation (HF) on Pulmonary Function in Carcinoma Breast patients treated with radiation therapy. Materials and Methods: A total of 75 patients with Carcinoma breast, who were candidates for adjuvant radiation therapy from August 2016 to Jun 2018 were included in this prospective study. Spirometry based PFT was done before radiation therapy as base line, at 1 month after RT and once in every 3 months for a year. Fifty patients were treated with 50Gy in 25 fractions and 25 patients with 40Gy in 15 Fractions to chest wall +/-SCF by 3DCRT. The variation in pulmonary functions were compared with the base line values and correlated with lung doses taken from DVH. Results: Before radiation therapy in the conventional fractionation arm, 7 (14%), 18 (36%), 20 (40%), 5 (10%) patients had normal, mild restriction moderate restriction and severe restriction in lung function respectively. At one month after radiation therapy 6 (12%), 15 (30%), 23 (46%), 6 (12%) patients had normal, mild, moderate and severe restriction of lung function respectively. At three months after radiation therapy, 8 (16%), 13 (26%), 20 (40%), 9 (18%) patients had normal, mild, moderate and severe restriction of lung function. In the hypofractionation arm, before radiation therapy, 5(20%), 10 (40%), 4 (16%), 5 (20%) patients had normal, mild restriction moderate restriction and severe restriction in lung function respectively. At one month after radiation therapy 4(16%), 4(16%), 10(40%), 6(24%) patients had normal, mild, moderate and severe restriction of lung function respectively. At three months after radiation therapy, 3(12%), 3(12%), 12(48%), 6 (24%) patients had normal, mild, moderate and severe restriction in lung function. In the conventional fractionation arm, there was a decrease in FVC from first month to 3rd month by 17.7% and in FEV1 by 15.3%. in the hypofractionated arm the decrease in FVC was by 17.8% and FEV1 by 41%. Conclusions: There was increase in the incidence of severe restriction of lung function post radiation in both the groups which was more in the hypofractionation arm. Further study with larger number of patients and longer duration of follow up is needed to confirm these observations.

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A prospective comparison of subjective and objective assessment of cosmetic outcome following breast brachytherapy

Tabassum Wadasadawala, S. Sinha, S. Verma, S. Kannan, R. Pathak, R. Sarin, V. Parmar, M. Gaikar

Aims/Objectives: Cosmesis after breast conservation therapy (BCT) has a major impact on quality of life and psychosocial functioning of women. Accelerated partial breast irradiation (APBI) is an emerging standard of care for selected patients with early breast cancer. This study intends to evaluate the co-relation of subjective and objective methods of cosmesis scoring in a brachytherapy cohort. Materials and Methods: All women treated with APBI using interstitial brachytherapy reported for clinical follow up every 6 months. In this prospective study, all consecutive patients who were 18 to 36 months post brachytherapy were screened and accrued after obtaining informed consent. Single cross-sectional assessment of the breast cosmesis was done by the radiation oncologist (subjective method) using Harvard scale and by photographic assessment using the BCCT. Core (the Breast Cancer Conservative Treatment. cosmetic results, version 3.1) software (objective method). In addition, patients scored their own cosmesis and reported self-satisfaction with the outcome of BCT. The correlation between subjective and objective methods for the overall score as well as individual subjective/objective domains was done using Spearman correlation coefficient and ANOVA. Individual domains were further tested for significance by logistic regression. Results: Overall cosmesis assessment by subjective method was Excellent/Good (EG) for 53 patients and Fair/Poor (FP) for 25 patients whereas it was 54 EG and 24 FP for assessment by BCCT. The correlation between subjective and objective assessment was good (85.8%) with a correlation coefficient of 0.673 (95% CI:0.495-0.850). 66 (86 %) patients rated their cosmesis as EG and 12 (15.4%) patients rated their cosmesis as FP. 77 patients (98.7%) were satisfied with overall outcomes of BCT. Correlation of individual subjective parameters with subjective and objective cosmesis is given in [Table 1]. Correlation of individual parameters of BCCT with subjective parameters is given in [Table 2]. Parameters significant for inferior cosmesis in subjective cosmesis assessment by logistic regression were appearance of scar (OR:7.312, 95% CI 2.1 to 24.9, p=.001), location of the nipple (OR 17.5, 95% CI 4.7% to 64.3, p value 0.001), shape of breast (OR:20.727,95% CI 3.8 to 111.0, p=.0001) and size of breast (OR :26.133,95% CI 6.3 to 106.8, p=.0001). Conclusion: Good correlation exists for overall cosmetic outcomes by subjective and objective methods. The results of this study suggest that location of nipple areola complex is the most consistent factor corelating with both subjective as well as objective methods of evaluation of cosmetic outcome.
Table 1

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Table 2

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Does compliance of the patients outweighs the other factors in the clinical outcome of hypofractionated radiotherapy? An analysis of the benefits of hypofractionation in postoperative breast cancer patients

S. N. Jagadesh Kumar, N. V. Kalaiyarasi, R. Giridharan, C. Sundaresan, Sanjal Kumar, P. R. Vijey Karthik, N. Poonkodi, Senthil Kumar

Department of Radiotherapy, BIRO, Madras Medical College, Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India

Aim: To assess whether compliance of the patients outweighs the other factors and to assess loco regional tumour control, the toxicities and quality of life of post operative breast cancer patients during and after hypofractionted radiotherapy. Methods: This is a two arm prospective study done in Department of Radiotherapy, BIRO, Madras Medical College. One arm is conventional fractionation and the other arm is a hypofractionation radiotherapy regime. A total of 60 patients were recruited, with 30 in each arm. Primary End point was loco regional tumour control and secondary end point based on compliance, toxicities, Quality of life and Compliance. Results: Of the conventional fractionation, majority had acute skin reactions, a major portion of them had compliance issue and quality of life issues. In the Hypofractionation arm, almost half of them had acute skin reactions whereas only one third of them had compliance and quality of life issues. In terms of locoregional control, results were almost similar in both the arms. Compliance was a major issue. Conclusion: Hypofractionation and Conventional fractionation had issues with each end point. This analysis presents a scenario where all the end points whether primary or secondary becomes to be important in female cancer patients especially the breast cancer. Finally compliance was the major factor in determining the clinical outcome.

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Comparative evaluation of volume of boost clinical target volume with or without intra-surgical clips in breast cancer

Abhay Pratap Singh, Rahat Hadi, Madhup Rastogi, Kamal Sahni, Ashish Singhal, Rohini Khurana, S. P. Mishra, Shantanu Sapru, Anoop Kr. Srivastava, Ajeet Kr. Gandhi, Avinav Bharati, Sambit S. Nanda, Prabha Verma, Niraj Agarwal

Aims and Objective: Boost to radiation cavity after whole breast radiotherapy (WBRT) in patients after breast conserving surgery is delivered either with photon or electrons. Delineation of cavity relies on clinical markers such as surgical scars, preoperative mammogram, seroma, intra-surgical clips. The purpose of this study was to evaluate the difference in the volume of lumpectomy cavity boost planning with and without intra-surgical clips in patients of breast cancer. We compared the CTV sizes of patients with clips and without clips. Materials and Methods: 28 patients were included in the study, out of which in 18 patients surgical clips were placed (arm A) and 10 patients were having no clips (arm B). Median age of patients included in the study was 46 years, 96% of patients (27) were of stage IIb, the median value of maximum diameter of tumor size of patients in arm A was 3.4cm (range 1.2cm to 5.6 cm) and of patients in arm B was 3.5cm (range 1.8 cm to 5 cm); the difference in size of tumor in both the arms was statistically not significant (p =.893). In both the arms, the most common quadrant involved was upper inner quadrant. The time gap between surgery to WBRT in 36% of patients was within 4 months and 36 % patients received radiation at 4 to 6 months gap. Results: The mean PTV breast volume was 909.56 cm3 (range 396.7cm3 - 2690.28cm3). The mean CTV boost volume of lumpectomy cavity in patients having clips was 99.83 cm3, median was 72.89 cm3 (range 41.46cm3 to 376.12) while in patients without clips mean CTV boost volume was 68.79 cm3, median 62.78cm3(range 23.64 to 213.16), difference in CTV volumes was statistically significant (p=.011). Conclusion: In our data, the volume of lumpectomy cavity was significantly higher in those patients in which intra-surgical clips were used for CT radiotherapy planning. The use of post-operative changes, pre-operative mammograms clinical diagrams for delineation of lumpectomy cavity may incorporate geographical miss or may include normal tissue. Still the common use of intra-surgical clips is not yet established.

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Dosimetric comparision of conventional and radiation therapy oncology group based radiotherapy of breast cancer: Are we treating the right volumes?

Prabha Verma, Kamal Sahni, Shantanu Sapru, Madhup Rastogi, Rohini Khurana, Rahat Hadi, Ajeet K. Gandhi, Abhishek Chauhan, S. P. Mishra, Sambit S. Nanda, Anoop K. Srivastava, Avinav Bharati, Syamantak Das, Sumanta Manna, Niraj Agarwal, Abhay P. Singh

Purpose: Radiotherapy planning in breast cancer is usually accomplished with conventional soft tissue/bony landmarks. Radiation therapy oncology group (RTOG) guidelines incorporate contouring volumes based on soft tissue/vascular anatomy. We aimed to assess dosimetric and volumetric differences in target volume and OARs between conventional treatment plans vi-à-vis RTOG contour based plans in patients of breast cancer. Materials and Methods: 35 patients of histopathologically proven infiltrating ductal carcinoma breast, aged 18-80 years including both mastectomy and breast conservation surgery (BCS) were enrolled in this prospective observational cohort study. Patients were treated with 50 Gray in 25 fractions with additional 10 Gray in 5 fraction boost in BCS patients by conventional treatment plans. On conventional plans edited PTVs were drawn retrospectively and then RTOG consensus guidelines were used to contour the breast/chest wall, level I, II and III axillary nodes, supraclavicular fossa(SCF) and internal mammary node(IMN). OARs contoured included heart, ipsilateral (I/L) and contralateral (C/L) lungs, C/L breast, esophagus and spinal cord. Dose volume histograms (DVHs) for these target volumes generated from conventional treatment plans. Further new treatment plans were generated based on RTOG target volumes, intended to cover >90%PTV by 90% of isodose line. DVH parameters of these 2 set of plans were compared using paired t-test. Results: Patient characteristics have been enunciated in [Table 1]. Volumes of RTOG contoured target volumes were larger. Mean volume of RTOG contoured breast/chest wall PTV covered by 90% isodose line(V90) was less with conventional plans as compared to conventional edited PTV (88.66±4.97 vs 92.3±3.58, p=0.0001). Similarly mean V90 for SCF (88.85±6.80 vs 92.62±3.50, p=0.002) and mean V90 for IMN (45.67±37.72 vs 59.34±38.10, p=0.002). and combined PTV V90 (87.19±3.90 vs 91.3±2.33, p=0.0001) was also less for RTOG contoured volumes in conventional landmarks based plans. However in RTOG contour targeted plans, coverage improved for RTOG target volumes. Mean volume of RTOG contoured breast/chest wall PTV covered by 90% isodose line V90 was better with RTOG plans compared to conventional plans (92.22±4.97 vs 88.66±3.62, p=0.001). Similarly mean V90 for total axilla (97.25±4.16 vs 90.51±11.28, p=0.0001), V90 for SCF (96.61±3.45 vs 88.85±6.80, p=0.0001), V90 for IMN (60.36±39.32 vs 45.67±37.72, p=0.001), and combined PTV V90 (91.69±2.21vs 87.19±3.90, p=0.0001) was also better for RTOG contoured PTVs with RTOG target volume based plan. As for OARs, conventional vs RTOG Dmean for heart was 2.67vs 2.85(Gy)(p=0.10) and V5Gy for heart was 8.48 vs 9.23(%)(p=0.29) respectively. For conventional Vs RTOG plans I/L lung V20Gy 30.12 vs 30.79(%)(p=0.054) and V5Gy for C/L breast was 0.52 vs 0.81(p=0.47) respectively. Conclusion: Our study showed RTOG guideline based target volumes had inferior coverage with conventional plans. On the contrary 3D-CRT plans directed at RTOG contours provide statistically significant better coverage for target volumes with non-significant increase in dose to the OARs.
Table 1

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Evaluation of deep inspiration breath hold technique with intensity modulated radiotherapy for carcinoma breast

Sameer Salahuddin, Jayaprakash Madhavan

KIMS Cancer Center, Thiruvananthapuram, Kerala, India

Introduction: IMRT as well as DIBH technique has shown to reduce doses to OARs in WBI after BCS for early breast cancer. Materials and Methods: 80 IMRT plans of 40 consecutive breast conserved female early breast cancer patients(two plans per patient, one Free Breathing and one Deep Inspiratory Breath Hold) equally divided between right and left sides were analyzed. Primary objective was to determine if DIBH technique is able to reduce radiation dose to the Heart. Secondary objectives were to determine if DIBH technique is able to reduce radiation dose to lungs and liver. All data was analyzed using the Statistical Package for the Social Sciences version 16.0. Results: In the left sided plans, we found a statistically significant reduction in all dose volume parameters specified for the heart with DIBH when compared to FB technique. The Heart Dmean was 5.5 Gy with FB and with DIBH it was reduced to 4.6 Gy,(p value 0.001). Conclusion: DIBH Technique with IMRT in WBI showed improved sparing of heart when compared to FB. Patients planned for left sided breast irradiation, capable of breath holding should certainly be treated with DIBH. Considering the advancements in radiation delivery technology, better availability of resources and expertise in Clinical Radiation Oncology in Kerala, DIBH technique should be considered a standard option in radiation treatment of early breast cancer.

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A comparision of doses to the PTV, heart and lungs in left sided postmastectomy carcinoma breast treated by IMRT and 3DCRT

Sugyan Nandan Mohanty, Bijayalaxmi Sahoo, Papuji Meher, Manoj Ku Behera, Lucy Pattanayak, Sanjukta Padhi, Niharika Panda, Diptirani Samanta, S. N. Senapati

Subject: To compare the dose distribution of IMRT versus 3DCRT in post mastectomy breast cancer patients. Materials and Methods: For 10 postmastectomy left sided breast cancer patients IMRT and 3D-CRT plans were generated for the radiotherapy of the chest wall. The prescribed dose was 40 Gy in 15 fractions. Dose-volume histograms were evaluated for the PTV and organs at risk. Parameters of the dose distribution were compared. Results: IMRT significantly reduced the ipsilateral mean lung dose(V20,20% vs 30%) and the dose to the heart decreased(V25,5% vs 10%) in all patients treated with left side breast carcinoma. The PTV showed a significantly better coverage and conformity index with IMRT plans. Conclusion: IMRT in comparision to 3DCRT significantly reduced the dose-volume of I/L Lung and Heart in Left sided breast cancer patients while optimizing the dose coverage to the target.

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Analysis from community outreach mammographic screening in North India

S. S. Bisht, T. Kataria, Deepak Gupta, Shikha Goyal, Susovan Banarjee, Kushal Narang, Nabila Anjum, Saumyaranjan Mishra

Introduction: Breast cancer is increasing in the developing countries. The risk factors are not easily modifiable therefore secondary prevention with screening is the way forward. Mammography (MG) remains the main modality of screening with significant decrease in breast cancer mortality. Most of this evidence is from developed countries. Demographics and tumor biology of Indian breast cancer patient is different from western world. Thus similar benefit of screening MG in low and middle income countries including India is debated. Furthermore data on the screening MG in Indian population is not available. Materials and Methods: Breast cancer screening through mobile MG van (Siemens) was inducted in 2012 as a part of community outreach program (Health camps) at our hospital. Asymptomatic nonpregnant females above the age of 40 years, who attended the health camps underwent bilateral breast (craniocaudal and mediolateral view) screening MG after consultation with oncologist. Females younger than 40 years with family history of breast cancer also underwent the test after the risk/benefit discussion. All MG were reported by in-house radiologist. MG data of 6159 cases from 238 camps conducted in urban and suburban region of north and central India between Feburary 2012- April 2018 were selected. Cases with history of breast cancer and unilateral MG were excluded (n=156). 6003 patients were selected. Patient were segregated in age bins : <40 yrs; 40-49yrs; 50-59 yrs; 60-69yrs and more than 69 years. BIRADS score, Tissue density, mammographic findings and laterality were noted. Cases with score 3 and above were traced for the ultimate presence or absence of breast cancer after the mammographic intervention. Results: We report the interim results of this ongoing registry. Incidence of screen detected positive cases will be presented subsequently. Conclusion: The average age of mammographic population was 52 years with majority of population (76%) in the 40-59 years. 20% of population was above 60 years. The incidence of BIRADS 0-2 was 87%, BIRADS 3 was 10.5%. BIRADS 4-5 constitutes 1.76%.
Table 1

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Axillary lymph node coverage with three-dimensional tangential field whole breast irradiation in postbreast conservation surgery patients: An institutional study

Minakshi Mishra, Lincoln Pujari, Jatin Soren, Lucy Pattanaik, Sanjukta Padhi, Niharika Panda, S. N. Senapati

AHRCC, Cuttack, Odisha, India

Purpose: The American College of Surgeons Oncology Group (Z0011) trial indicated no benefit from axillary lymph node (LN) dissection after a positive sentinel LN biopsy in patients receiving whole breast irradiation, suggesting that level I-II LNs were covered in tangential fields. Aims and Objectives: To evaluate the axillary lymph node coverage in post breast conservation surgery patients who received whole breast radiotherapy by 3-dimensional tangential field irradiation. Materials and Methods: Sixteen computed tomography–based tangential whole breast radiotherapy plans were evaluated which were planned for a total prescribed dose of 40 Gy in 15 fractions. Level I, II and III axillary LNs were contoured using Radiation Therapy Oncology Group guidelines. The mean and median dose coverage of the three different levels of axillary lymph nodes were calculated. Results: Mean and median dose coverage of Level –I axillary lymph nodes were 36.74 Gy and 37.14 Gy, which were 91.84% and 92.84% respectively of the prescribed dose of 40 Gy. Similarly, mean and median dose coverage of Level –II axillary lymph nodes were 30.59 Gy and 31.21 Gy, which were 76.48% and 78.01% respectively of the prescribed dose. Further, Mean and median dose coverage of Level –III axillary lymph node were 10.51 Gy and 5.72 Gy, which were 26.27% and 14.3 % respectively of the prescribed dose. Conclusion: In this review of conformal CT-based 3-dimensional tangential whole breast irradiation plans, level-I LNs were covered by approximately 92% of the prescribed dose which is inadequate. In only 31% of cases, Level-I lymph nodes were covered by 95% of the prescribed dose. Doses to level-II LNs were around 76.5 % of the prescribed dose which was sub-therapeutic. Doses to Level-III axillary LNs were minimal with only 26% of the prescribed dose. In this group of patients, a standard tangential radiation field did not provide significant therapeutic coverage of level-I and Level-II LNs and provided negligible coverage of level-III LNs.

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Correlation between response to neoadjuvant chemotherapy and molecular subtypes of breast cancer patients

Sagar Raut, Rajesh Pasrich, Deepa Joseph, Sweety Gupta, Manoj Gupta, T. S. Aathira

Aim/Objectives: To compare the pathological response to neoadjuvant chemotherapy in different molecular subtypes of breast cancer. Materials and Methods: A total of thirty-onepatients who received neo-adjuvant chemotherapy between Jan 2018 to September 2018 for locally advanced breast cancer followed by definitive surgery were evaluated retrospectively. Clinical and pathological data of all patients were available for analysis. Tumours were divided into different molecular subtypes based upon IHC markers, luminal A (ER+/PR+/Her2Neu-/Ki67 <14), luminal B HER 2 Negative (ER+/PR+/Her2Neu- /Ki67 ≥14)luminal B HER 2 positive (ER+/PR+/Her2Neu 3+/Ki67 ≥14), HER 2 over expressed (ERany/PRany/Her2Neu3+ /Ki67 any) and triple negative (ER-/PR-/Her2Neu1+ /Ki67 any). Primary end point was correlation of pathological response [pathological complete response (PCR), pathological partial response, stable disease and progressive disease] of Neoadjuvant Chemotherapy with molecular subtypes in the study population. Results: A total of thirty-onepatient's data were analyzed. Three (9.67%) were luminal A, eight (25.80%) were luminal B, out of eight luminal B patients, five (62.5%) were HER 2 + and three (37.5%) were HER 2 –ve. Eight (25.80%) patients were HER 2 over expressed and ten (32.25%) were triple negative, 2 (6.45%) unclassified. A total of six(19.35%) patients out of 31 achieved PCR. Luminal A with zero patient having PCR, all 3 patients had partial response to neoadjuvant chemotherapy. Luminal B having zero patient with PCR and out of five Luminal B Her2 +, three had stable disease and two had partial response. Out of three Luminal B Her2 -, two had stable disease, one had partial response. One patient from Her2 over expressed had PCR, four patients had partial response, one patient had stable disease. 5(83.33%) patients in triple negative subtypehad PCR, one patient had stable disease, four patients had partial response. Zero patient in unclassified had PCR while one had partial response, other had stable disease. Conclusion: In our study population, best response to neoadjuvant chemotherapy was seen in patients with Triple negative molecular subtype and worst response was seen with Luminal B subtype.

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A dosimetric comparison of whole breast irradiation with conventional and conformal radiation techniques

Praloy Basu, Arnab Adhikary, Jyotirup Goswami, Suman Mallik, Shyamal Kumar Sarkar

Aims and Objectives: Modern radiotherapy treatment planning and delivery systems allow forward planned 3D dose distributions to be calculated and delivered to the breast using multi-leaf collimators. Studies have reported improvement in the dose homogeneity within the irradiated breast with added sparing of the heart and lung when intensity modulation was used. This study aimed to demonstrate an advantage of conformal techniques in the form of increased dose homogeneity in the target tissue while decreasing the dose to the organs at risk. Materials and Methods: At the Department of Radiotherapy, MCH, histologically proven cases of Carcinoma Breast were screened for this study. The patients, after breast conserving surgery, underwent post-operative radiotherapy. Simulation was done on a breast board using the Phillips 16 slice CT simulator and conventional and conformal (3DCRT & IMRT) plans were generated on ECLIPSE and MONACO TPS respectively. Dosimetric parameters were compared using IBM SPSS version 23. Results: The PTV V95 for conventional RT, 3DCRT and IMRT were 92.60+/-2.80%, 97.83+/-0.59% and 98.44+/-0.51%. Statistically significant advantage of 3DCRT over Conventional RT and IMRT over 3DCRT were found for V20 (29.08+/-2.34%, 15.89+/-1.47% and 14.71+/-1.50% for conventional RT, 3DCRT and IMRT respectively with p <.001) and Mean Lung Dose for ipsilateral lung and mean heart dose (10.78+/-1.05Gy, 7.92+/-1.20Gy and 6.55+/-0.81Gy respectively) in case of left breast irradiation. However the mean lung dose for contralateral lung was more in case of IMRT v/s 3DCRT (1.065+/-0.25Gy v/s 0.8+/-0.06Gy, p<.001). Conclusion: 3DCRT remains the standard for whole breast irradiation providing considerable statistically significant benefit over Conventional Radiotherapy. IMRT shows dosimetric promise but there is lack of compelling data to make it the standard of care.

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Capecitabine with temozolomide versus capecitabine only in oligo brain metastasis from carcinoma breast: A prospective randomized controlled trial

Pallavi Kalbande

Introduction: Brain metastasis occurs in 21% of patients those dying from breast cancer. Temozolomide is oral alkylating agent with ability to cross blood brain barrier withless toxicity profile. Capecitabine has also shown activity in brain metastasis her 2 enriched breast cancer with lapatinib. Our study analyses that, is the combination of two drugs with different mechanism of action result in improvement in overall survival. Aim of Study: Compare Median overall Survival after diagnosis of brain metastasis in both groups. Materials and Methods: 134 female breast cancer patients with oligo brain metastasis, KPS>70 were included. Extracranial metastasis was ruled out. All patients were treated with whole brain radiotherapy 30 Gy/10# on 6MV. In group A 65 patients received concurrent Temozolomide 75 mg/m2 with radiation followed by 200 mg/m2 for 5 days 28 days cycle and Tab Capecitabine 1800 mg/m2 in two divided doses from day 1 to day 14, 21 days cycle for total 6 cycles. In group B 69 patients received only Tab Capecitabine 1800 mg/m2 in two divided doses with same schedule for 6 cycles after WBRT. Results: Median age in both groups was 44 years. Median follow up period was of 2.5 years ranging from 2 to 3 yrs. Median survival in group A was 15 months and in group B was 14 months. Conclusion: Though several studies have shown partial response with combination of Temozolomide and Capecitabine it does not interpolate.


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