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Year : 2019  |  Volume : 15  |  Issue : 9  |  Page : 181-195


Date of Web Publication28-Nov-2019

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How to cite this article:
. Breast. J Can Res Ther 2019;15, Suppl S2:181-95

How to cite this URL:
. Breast. J Can Res Ther [serial online] 2019 [cited 2021 May 7];15:181-95. Available from: https://www.cancerjournal.net/text.asp?2019/15/9/181/271704

 > Abstract: 114: Psychosocial stress and quality of life assessment in breast cancer survivors: A prospective evaluation Top

Anu Tiwari, Rajesh K. Agarwal, Zehra Fatima, Dulal Kiran Mondal

Royal Cancer Institute and Research Centre, Kanpur, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): To assess the psychosocial stress and quality of life in breast cancer survivors. Materials and Methods: A sample of 86 breast cancer survivors participated in this survey who had been interviewed during the first year of their primary treatment. Inclusion criteria for this study were the completed 3 months follow-up post- treatment & there is no evidence of any metastasis disease. All were above 18 yrs, had no history of mental illness. A cohort of these survivors were interviewed in person by a trained Psychologist. The questionnaire included standardized instruments to assess stress by using Perceived Stress Scale to understand their psychological distress. The in-person interviews expanded on these questions and systematically further assessed them on HAD (Hospital Anxiety & Depression) for Psychological co-morbidity. Results: The scores showed a significant amount of stress in maximum number of patients. In spite of relatively good physical and emotional functioning. Depression (25%) and Anxiety (38%) was also notified among the survivor. Higher level Stress (56%) was observed, with increased duration of treatment. The middle-class female who were housewife and were above 40 yrs had higher stress level of 63%, 66%, 74% respectively, as compared to the other category. The early stage disease patient had higher level of stress (47%) probably due to good survival index. Conclusion: Holistically the survivors of breast cancer lead their life in conventional way. However, when the Patients were evaluated on Psychological parameter there was subclinical evidence of stress observed in this group.

 > Abstract: 152: Radiation induced pneumonitis after adjuvant conformal radiotherapy for breast cancer: A prospective follow-up study Top

Pawan Kumar, Rohitashwa Dana, Prashant Dadhich

SMS Medical College and Hospital, Jaipur, Rajasthan, India, E-mail: [email protected]

Background: Adjuvant loco-regional radiotherapy is an important component in treatment of breast cancer as it reduces loco-regional recurrence and improves overall survival. Radiation pneumonitis (RP) is one of the acute adverse events of radiotherapy, because lung is a major organ at the risk in radiotherapy planning for breast cancer. Purpose and Objective(s): To find out the occurrence of RP in breast cancer patients after Adjuvant Conformal Radiotherapy and its correlation with irradiated lung volumes and pulmonary function parameters. Materials and Methods: This is a hospital based prospective quantitative follow up study. After approval from institutional ethical committee, 80 breast cancer patients who received adjuvant conformal RT at SMS Hospital, Jaipur in between june 2018 to may 2019 were registered. Clinical assessment including screening for respiratory symptoms, chest radiograph and pulmonary function tests (PFTs) were done at baseline and 12 weeks after the completion of radiotherapy. Measurement of irradiated lung volume parameters were done on simulator film. Statistical analysis was done by using SPSS version 26 software. Results: Among the total registered patients, 1 patient expired after 15 days of completion of radiotherapy and 3 patients lost subsequent follow-up, so total 76 patients were evaluated for occurrence of RP up to minimum of 12 weeks. Radiological and clinical RP was seen in 43.42% (n=33) and 21.05% (n=16) respectively. Occurence of RP was significantly higher with age >50 years (p-value <0.05) and larger irradiated lung volume parameters (>3 cm) i.e. central lung distance (CLD), maximum lung distance (MLD), superior and inferior lung distance (SLD, ILD). There was no significant difference noticed with other patient and treatment related factors like laterality of breast cancer, either supraclavicular fossa irradiated or not, either boost to the chest wall/ axillary nodes received or not. Forced expiratory volume in one second (FEV1) and FEV1/forced vital capacity (FVC) ratio (also called Tiffeneau- pinelli index) of pulmonary function indices were significantly reduced post radiotherapy. Conclusion: Age >50 years and higher irradiated lung volume (>3 cm) were associated with increased RP. So the factors associated with increased RP should be considered for selection of better radiotherapy plan which may subsequently reduces the chances of radiation pneumonitis and helps in maintaining good quality of life in breast cancer survivors.

 > Abstract: 154: Study on hormone receptor status in patients with operable breast cancer at Regional Institute of Medical Sciences, Imphal Top

James Lalzuitluanga Chongthu, T. Dhaneshor Sharma

Regional Institute of Medical Sciences, Imphal, Manipur, India, E-mail: [email protected]

Purpose and Objective(s): In India, Breast Cancer is the most common cancer in females and hormone receptor status is an important prognostic and therapeutic tool in the management of breast cancer. This study was done with the aim to evaluate the hormone receptor status in patients with operable breast cancer at Regional Institute of Medical Sciences, Imphal, Manipur. Materials and Methods: This study is a retrospective case series study on 180 cases of operable breast cancer who were registered at the Department of Radiation Oncology, Regional Institute of Medical Sciences (RIMS), Imphal after histopathological confirmation during the period from September 2015 to August 2018 and patients were reviewed for age, tumour size and metastatic lymph nodes positivity, histopathology, grading, hormone receptor status, staging and menstrual status. Results: Overall 180 patients were studied and evaluated for hormone receptor status. 90 cases (50.0%) were both ER-/PR-, 66 cases (36.7%) were both ER+/PR+, 14 cases (7.8%) were ER+ and 10 other cases (5.5%) were only PR+. The mean age of presentation was 52.6 ± 0.82 years and the number of patients reaches a peak between 31-50 years (59.4%). Maximum patients were found to be in poor socio-economic class. Invasive duct carcinoma (96.1%) was predominant histology. Majority of the cases (84.5%) had grade-III tumour. 17.8% of total patients presented in stage-I, 42.8% in stage-II and 39.4% in stage-III. Conclusion: In Manipur, incidence rate of breast cancer among younger age group has been increasing and more patients were ER/PR negative. Maximum numbers of grade-III tumour were found to be ER/PR negative and as the tumour size increased, ER/PR negativity also increased.

 > Abstract: 156: Prognostic factors influencing cerebral progression from carcinoma breast and its impact on time to development Top

Priyanka Augustine, A. G. Hasib

Kasturba Medical College, Manipal, Karnataka, India, E-mail: [email protected]

Aim: To analyse the prognostic factors that could contribute to the progression to brain metastasis in Ca Breast patients and to assess its influence on time to development. Materials and Methods: Retrospective data analysis of 22 carcinoma breast patients with brain metastasis who received Whole Brain Radiotherapy between January 2014 to September 2017 was done. Median time to cerebral progression was analysed in those who had non-metastatic disease at presentation and was analysed with respect to Stage of disease, Grade of tumour, Hormone Receptor as well as HER2 neu status and treatment with Trastuzumab in case of HER2 neu positive tumours. Statistical analysis was performed by using Fisher Exact test. Results: Out of the 22 patients analysed, 14 patients were non metastatic at presentation and 8 patients were upfront metastatic. The median time to cerebral progression in patients with non-metastatic disease at presentation was 14 months (range 1-108 months). For Stage II disease, it was 27 months (range 1 – 108 months), for Stage III disease it was 9 months (p = 0.1052). The median time to cerebral progression was 37 months for those with Grade 2 tumours and 9 months (range 7 – 15 months) for those with Grade 3 tumours. (p = 0.0146). In ER/PR+ tumours the median time to cerebral progression was 24 months whereas for those with ER/PR– tumours it was 13 months. (p = 0.0105) For the HER2 enriched subgroup, it was 8 months whereas for HER2– group the median time was 15 months. (p = 0.4766). For patients with HER2+ positive tumours who received Trastuzumab, the median was 15 months compared to 8 months in those who did not receive Trastuzumab. (p=1.000). Additionally, in patients who had brain as the first metastatic site, the distribution of hormonal subtypes was as follows: Luminal A-0 (0%), Luminal B-2 (20%), Her 2 neu enriched-2 (20%), Triple negative -6 (60%). Conclusion: This study has enabled the identification of a subset of carcinoma breast patients who are at an increased risk for early development of brain metastasis. Those with Grade 3 tumours (p=0.0146) and ER/PR- tumours (0.0105) had statistical significance and a shorter duration to cerebral progression. Those with Stage III disease, HER2 overexpressed tumours and those with HER2+ disease who did not receive Trastuzumab had a shorter time to development of brain metastasis but was not found to be statistically significant.

 > Abstract: 157: Dosimetric superiority of prone position in radiotherapy of early breast cancer following conservative surgery Top

Dipalee Borade, Shyam Kishore Shrivastava, Sandeep De, Wasim Phophlunkar, Suresh Chaudhari, Ashwani Singh

Apollo Hospitals, Navi Mumbai, Maharashtra, India, E-mail: [email protected]

Breast cancer is the most commonly diagnosed cancer in women (24.2%, i.e. about one in 4 of all new cancer cases diagnosed in women worldwide are breast cancer. Ductal carcinoma in situ (DCIS) is a relatively common diagnosis among women undergoing screening mammography and treated aggressively with surgery and radiation therapy. With the improvement with survival rates it is important to reduce the treatment related side effects. Five-year survivors who had received radiotherapy during their breast cancer primary treatment were at a higher risk of death from overall cardiovascular diseases, and cardiac diseases, as compared to women who had not received radiotherapy. Rates of major coronary events increased linearly with the mean dose to the heart by 7.4% per Gray. In supine position, even with tangential field intensity modulated radiotherapy (IMRT) planning the heart and lung will get the dose. Supine multi-beam IMRT (MB-IMRT) may overcome those limitations often at cost of low- or intermediate-dose spread over the contralateral breast and ipsilateral thoracic region. In prone position taking advantages of gravity, the breast moves away from the chest wall and lung. We report the dosimetric comparison of radiotherapy treatment in prone and supine position. Materials and Methods: Patient with stage 0, I or IIA disease who underwent breast conservation surgery, margin negative and node negative or 1-3 node positive cases, with all sizes irrespective of side were simulated in both supine and prone positions. Inversely planned Intensity Modulated Radiotherapy (IMRT) plans were generated on both supine and prone scans of the same patient, for 40 Gy/15 Fr to whole breast followed by boost to the tumor bed with 12.5 Gy/5 Fr. Dosimetric analysis was done for both supine and prone plans for 15 patients. Dose volume histograms were generated for plan evaluation and comparison. Results: Both plans achieved acceptable coverage of the breast. The mean percentage of the breast receiving at least 95% of the prescription dose (V95%) were almost similar in the prone and supine positions, 88.5% versus 91.6%. The mean heart dose was decreased by 52% in prone position. The mean lung dose was decreased by 83% in prone position compared to supine position. The percentage of ipsilateral lung receiving 20 Gy was substantially reduced from 22.26% supine to 2.26% in prone (P - 0.001). In field heart volume was 1.37 cc for prone position and 21.56 cc for supine position. In field lung volume was 16.26 cc for prone and 224 cc for supine position. There was decrease in the dose to the contralateral breast in prone position. Conclusion: Prone breast radiotherapy is superior than the radiotherapy in supine position. The dosimetric superiority in prone position was seen in all breast volumes but more pronounced in large and pendulous and left sided breast.

 > Abstract: 188: Clinical evaluation of acute and late effects in postmastectomy carcinoma breast patients underwent radiation therapy with field-in-field three-dimensional conformal radiotherapy technique Top

Shalu Verma, Virendra Bhandari, Sumit Gupta, Sahaj Palod, Aafreen Khan, Tauseef Ali

Sri Aurobindo Medical College and Postgraduate Institute, Indore, Madhya Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): To evaluate acute and late toxicities in carcinoma breast post-mastectomy patients treated with FIF-3DCRT. Materials and Methods: Twenty-six post-mastectomy breast cancer patients were selected for this study. Computed Tomography (CT) simulation was done after proper immobilization using breast board. Then CT scan images were transferred to treatment planning system (TPS) after delineation. Then planning was done and best plan was selected. All patients with external beam radiotherapy received a dose of 50 gray (Gy) in 25 fractions (#) with photons followed by boost of 10 Gy in 5 # with electrons. All the patients were assessed for acute toxicities during the treatment and late toxicities till one-year follow-up. Results: In our study, skin toxicities grade (Gr) I in 69%, Gr-II in 26%, Gr-III in 3% only in axillary region, symptomatic radiation induced pneumonitis in 11%, arm oedema in 3%, post radiation fibrosis in lungs Gr-I 42%, Gr-II in 7.6% and productive cough in Gr-I 36%, Gr-II 7.6% with no contralateral breast oedema or cardiac toxicities in any of the patient. Conclusion: Patients treated with FIF-3DCRT have less acute and late toxicities and no patients have grade 4 or higher toxicity. FIF-3DCRT have increased therapeutic ratio with very less doses to normal organs as well as it does not increase financial burden on patients and thereby providing improved results without monetary burden of higher techniques in patients.

 > Abstract: 192: Role of postmastectomy radiotherapy in T1, T2 lesions with 1-3 positive axillary lymph nodes: A retrospective study of 101 cases Top

Akansha Bajpai, Rajen Tankshali

GCRI, Ahmedabad, Gujarat, India, E-mail: [email protected]

Introduction: Post mastectomy radiotherapy (PMRT) reduces loco-regional recurrence (LRR) and improves overall survival. There is international consensus to recommend PMRT for patients with tumour size more than 5 cm (T3), tumour invasion of skin, pectoral muscle or chest wall (T4) and patients with > 4 positive lymph nodes (LN). However, the role of PMRT for patients with T1, T2 disease with 1–3 positive LN is still controversial. The side effects of radiotherapy and its associated morbidity have to be considered in the risk benefit ratio, thus difficult to arrive at consensus in early breast cancer. In a developing country like India, factors such as patient education, level of awareness, financial aspect, long term follow up, limitation of resources have to be balanced and tailored according to the indication and need of the patient. Objectives: 1. Empirically explore whether it is advisable to carry out radiation when there are 1-3 nodes. 2. Whether Perinodal extention in this subgroup is an important parameter to consider for radiotherapy. Materials and Methods: We collected data after approval from our institutional board review committee and analysed case files of patients who presented and were treated at our governmental tertiary referral centre from a period between 2014-2017. Of the 691 patients who underwent mastectomy, we short listed 101 cases for our study who fulfilled our basic inclusion criteria of T1,2 N1 on final histopathology. The inclusion criteria for this analysis were: (1) Female patients with unilateral breast cancer and no distant metastasis at initial diagnosis who underwent mastectomy and axillary lymph node dissection; (2) postoperative pathology indicated T1–2 and 1–3 positive axillary lymph nodes (T1–2N1M0) disease, at least 10 lymph nodes removed by axillary dissection; (3) complete surgical resection of the tumor and negative margins; (4) complete estrogen receptor (ER), progesterone receptor (PR) and human epithelial growth factor receptor family 2 (Her2) status; (5) No neoadjuvant chemotherapy was administered before surgery and endocrine therapy was performed based on the hormone receptor status. In order to study the research questions, we formulated hypotheses as follows, 1. Radiotherapy does not have any impact on recurrence post mastectomy. 2. There is no influence of Peri nodal extention on recurrence. The above hypotheses were tested using chi-square test. Results: On applying chi square test we found out the observed and the expected value Radiotherapy was given in 60 patients and 41 were not given. Recurrences were obtained in 9 amongst radiotherapy and without radiotherapy in 16. When chi square was appliedwith 1 degree of freedom, the value was highly significant at 0.006 with 99% CI. Hence our hypothesis was rejected. Also in case of PNE with recurrence and radiotherapy, 8 had PNE with radiotherapy and recurrence and 27 had no recurrence, on computation degree of freedom was 3 and p value was 0.013% hence highly significant. Conclusions: Radiotherapy.

Abstract: 203: A comparison of Prognostic significance between Her 2 Enriched and Triple Negative type Breast cancer post Whole Brain Radiation in Brain metastasis in Treatment completed Invasive Breast cancer; A Retrospective analysis from a Prospectively maintained Database

Bhukya Swetha, Kushal Goswami, Anish Bandyopadhay, Amitabha Manna

Medical College and Hospital Kolkata, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): The primary end point was to asesss the Survival post Brain Metastasis & clinical/radiological Response post WBRT in primary metastastic site (CRPMS) and the assessment of neurologically unimpaired quality of life (NUQOL) and correlate them with the two Arms of our study (Her 2+ enriched (GRP A) Vs TNBC type Breast cancer (Grp B). A secondary end point was to correlate the no of cycles of AntiHer2+ therapy received in GRP A Prior and after to brain metastasis with the same primary end points. Materials and Methods: From 2013-2018 September, 169 patients with Primary Treatment completed IDC Breast presented with either oligo or multiple brain metastasis (radiological). Among them 66 were of Triple negative variant (Grp A), and 49 were of Her 2 enriched luminal B criteria (Grp B) Applying our inclusion criteria which were

  • Age <60 yrs
  • Her2 enriched…. only with IHC Proven Her 2 3+
  • Complete IHC profile
  • Less than 3 adj/maintenance trastuzumab in Grp A.

We got to our sample population

GrpA= 57 vs Grp B= 37

WBRT was given to all. Survival post Brain mets (SPBM), Radiological status (as Per RANO) & neurologically unimpaired quality of life (NUQOL) was primarily associated with the two luminal groups (Her2 enriched vs TNBC). A secondary analysis was also carried on GRP A with the no of Adjuvant Trastuzumab received vs the same primary end points. For secondary analysis on GRP A we took out the exclusion criteria of <3 cycles adj/maintenance Trastuzumab and that gave us a sample size of 49 (The total no of Her 2 enriched pt with brain metastasis treated during this time). Results: Survival post Brain metastasis was significantly more in Her 2 Enriched luminal group. Radiological PR/CR was observed slightly more in the TNBC group which however didn't translate to SPBM. Neurologically unimpaired quality of life was again significantly higher in the Her 2 enriched group. On subgroup analysis Her 2 enriched pt with <2 mets has Both superior SPBM and NUQOL. Addition of trastuzumab after WBRT was associated with significant improvement of SPBM, although the last analysis was on a very small sample size, so it could not be validated by logistic regression.

 > Abstract: 229: Comparison of cardiac and lung doses with deep inspiratory breath hold and free breathing techniques in patients receiving radiotherapy for carcinoma left breast: A pilot study Top

Swathi Bapani, B. Selvamani, S. Patricia, K. Mohamathu Rafic, T. Joel, Abel Juhan Thomas, B. Rajesh, Paul Ravindran

Christian Medical College, Vellore, Tamil Nadu, India, E-mail: [email protected]

Purpose and Objective(s): To compare the heart, left anterior descending artery (LAD), and lung doses in patients with carcinoma left breast receiving adjuvant radiotherapy to chest wall and regional nodes using DIBH and standard free breathing technique (FB). Materials and Methods: This hospital based observational prospective study was conducted from March 2018 to August 2019 on patients diagnosed with left sided carcinoma breast receiving adjuvant loco-regional radiotherapy i.e. chest wall (CW), supraclavicular fossa (SCF), internal mammary region (IMC) with or without axilla. Fifteen patients were recruited for the study and immobilized using breast board and 5 degree wedge with arms above head. Respiratory cycle was tracked with localizer box and monitoring by RPM software. Two sets of planning CT with 2 mm slice thickness were obtained both in DIBH and FB. Standard fractionation regimen of 50Gy in 25 fractions over a period of 5 weeks was used for all patients in the study. The difference between DIBH and FB technique parameters were compared using Wilcoxon sign rank test using SPSS software version 21.0. Results: Comparison of DIBH and FB parameters for target coverage showed statistically significant advantage with DIBH in SCF (D95, V90, p<0.017) and IMC (D98, V90 & V95, p<0.03) but no difference in chest wall. Dosimetric characteristics of heart and LAD showed statistically significant low dose with DIBH (V20, V25 and Dmean, p<0.001) as compared to FB. Lung doses by both techniques were similar with no advantage of one over another. Other OARs such as contralateral breast and oesophagus received lower dose with DIBH technique but spinal cord and thyroid showed no difference. Conclusion: DIBH shows a substantial reduction of cardiac and LAD doses but insignificant reduction of ipsilateral lung doses as compared with FB technique when regional nodes including IMC is treated. DIBH technique requires appropriate patient selection, training and technical expertise which can effectively reduce the cardiac morbidity without compromising chest wall target coverage and improving regional node coverage. DIBH should be considered for left sided breast cancer when patient can hold breath as required. The advantage of low dose to lungs in DIBH is lost when regional nodes such as IMC are treated.

 > Abstract: 237: Hybrid RT planning using VMAT and 3DCRT for postmastectomy carcinoma breast Top

L. Sofia

GVN Hospital, Tiruchirappalli, Tamil Nadu, India, E-mail: [email protected]

Purpose: The purpose of this study is to compare the dosimetric data and evaluate the potential benefits of Hybrid plans generated using 3-dimensional conformal tangential fields and volumetric modulated arc therapy for left sided post mastectomy carcinoma breast patients. Methods: Nine patients of left sided post mastectomy carcinoma breast patients, treated earlier by conformal tangential fields were selected for this retrospective study. For each patient, a hybrid arc plan was generated using standard tangential fields and Coplanar volumetric modulated arc fields in dose ratio of 80:20 and 60:40. The prescription dose to the PTV was 50Gy in 25#. Doses were compared between 3DCRT, VMAT and Hybrid plans of each patient. The differences among these hybrid plans were analysed using paired t-test and wilcoxan rank sum test. Results: The hybrid arc plans achieved the clinically acceptable PMRT plan constraints. However VMAT plan showed better CI (conformity index) and DHI (dose homogeneity index) than HYBRID plans and hybrid plans are better than 3DCRT. For normal tissues, hybrid plans showed significantly better OAR sparing and showed advantages in the V5 of the lung, V25 of the heart and left ventricle, V5 contralateral breast. The average beam on time and monitor units of hybrid arc plans were significantly lower than VMAT plans (P<0.001). Conclusion: The disadvantages of standard tangential fields and VMAT plans for PMRT can be overcome by using hybrid plan. It is feasible and can be exploited by using differential dose ratios as per the co-morbidities of each individual patient.

 > Abstract: 240: Dosimetric analysis of intensity modulated radiotherapy and volumetric modulated arc therapy in postmastectomy radiotherapy in patients with left sided carcinoma breast Top

Akanksha Singh, S. Shyama Prem, Phaneendra Mettapalli, R. Seenisamy

JIPMER, Puducherry, India, E-mail: [email protected]

Purpose and Objective(s): The management of locally advanced breast carcinoma is multi-modality and includes surgery, neoadjuvant/adjuvant chemotherapy and adjuvant radiotherapy. Tangential fields are used in the treatment of chest wall because it avoids lung and heart maximally. However, inevitably portions of lung and heart will be included in the tangential fields. VMAT and IMRT are intensity modulated treatments which achieve highly conformal dose distribution to the target volume sparing critical organs. Our study was undertaken to compare the dosimetric parameters between Intensity Modulated Radiotherapy and Volumetric Modulated Arc Therapy in post mastectomy patients with left sided carcinoma breast. Materials and Methods: We conducted a hospital based cross sectional study in patients with locally advanced breast cancer who had undergone mastectomy and referred for chest wall radiotherapy. 25 patients were recruited and were subjected to a non-contrast CT simulation. 2 plans were generated for CT data of each patient- VMAT with 2 partial arcs each for the chest wall and supraclavicular fossa and IMRT with 7 fields each for the chest wall and the supraclavicular fossa. The dose prescribed was 50Gy in 25 fractions. So, a total of 50 plans were generated for comparison and analysis of dosimetric parameters. Mean with S.D. was reported for normally distributed variables median and IQ range was reported for non-normally distributed variables. Results: The PTV dose coverage in VMAT was equivalent to that of IMRT plan. In VMAT plans, the mean volume receiving 47.5Gy (V47.5Gy) was 98.61% (±2.66). In IMRT plans, the mean was 96.22% (±2.69). The difference was not statistically significant (p-value: 0.375). The homogeneity index (HI) was 0.2 (±0.1) in VMAT and 0.15 (±0.09) in IMRT (p-value: 0.110). The conformity index (CI) in VMAT [Mean: 1.04 (±0.13); Median: 0.99 (0.96-1.17)] had no significant difference to that of IMRT [Mean: 1.12 (±0.15) (p-value: 0.065). The mean heart dose (12.37Gy vs 14.32Gy; p: 0.001), V5Gy (83.12% vs 93.58%; p: 0.001), V10Gy (44.54% vs 51.72%; p: 0.008), V20Gy (16.81% vs 21.52%; p: 0.008), and V30Gy (8.04% vs 10.49%; p: 0.009) for VMAT were significantly lesser than IMRT. For the ipsilateral lung, V10Gy (46.46% vs 53.51%; p: 0.032) and V20Gy (28.49% vs 26.57%; p: 0.028) were significantly lesser for VMAT plans. The 40Gy for the lung (9.03% vs 7.55%; p: 0.002) were significantly higher for the VMAT plans when compared to IMRT plans. The mean lung dose (15.67Gyvs 16.05Gy; p: 0.757) and V30Gy (17.58% vs 17.16%; p: 0.201) were not significantly different in both the plans. The mean dose to the contralateral breast was significantly higher for the VMAT plans when compared to the IMRT plans (6.05Gy vs 5.43Gy, p: 0.005), while the doses to the contralateral lung were not significantly different (5.29 vs 5.33; p=0.17). The monitor units in VMAT were significantly lesser than IMRT (906.4 vs 2141.92; p: <0.001). Conclusion: VMAT is dosimetrically superior to IMRT for left-sided breast cancer patients owing to its equivalent PTV coverage and better sparing of heart and left lung. The advantages of the VMAT include lesser Monitor units and reduced treatment time which can improve the compliance to the treatment and intra-fractional motion errors.

 > Abstract: 241: Patient set up variations in CT based treatment planning for left sided breast cancer using electronic portal images Top

Sachin Taneja

INHS Asvini, Mumbai, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): To Determine Patient Set Up variations In CT Based Treatment Planning For Left Sided Breast Cancer Using Electronic Portal Images (EPIs). Background and Aim: This study deals with isocentric variations for along with the set up reproducibility and determining the random and systematic errors in a cohort of 25 (females) left sided breast cancer patients treated with mega voltage X rays using an online electronic portal imaging (EPI) protocol. Materials and Methods: This is a hospital based cross sectional observational study which was carried out on 25 female patients of carcinoma breast (left sided) who had undergone modified radical mastectomy (MRM) were enrolled in the study. After completion of the planned chemotherapy, all patients underwent virtual 3D CT simulation and an External Beam Radiotherapy (EBRT) treatment was planned on these 3D CT images on a treatment planning system (TPS) using two (coplanar) / conventional tangential fields for a total dose of 50 Gy in 25 fractions. Analysis of 150 electronic portal images (EPIs) determined changes in the treatment fields during set up of these 25 patients. Online assessment included set up deviations in all the three directions (AP, SI and ML) and variations in Central Lung distance (CLD) during the first three fractions. Results: Random errors ranged from 1-5 mm for the chest wall (medial and lateral) tangential treatments and 1 mm for the anterior supraclavicular nodal field. Systematic errors ranged from 2.5-4.5 mm in the Antero-posterior (AP) direction for the tangential fields and from 2.5-7.5 mm in the Supero-inferior (SI) and Medio-lateral (ML) direction for the anterior supraclavicular nodal field. For 25 (left-sided) patients, the CLD (treatment planning system) were 20-30 mm, CLD (EPIs) were 25-40 mm showing a variations of 5-10 mm, V20 is 1.0 -6.0 Gy, maximum total lung dose is 43 Gy, V30 were 2.0 - 4.0 Gy, and maximum heart dose was 52 Gy and maximum spine dose as 45 Gy. Conclusion: Online assessment of patient position with matching of EPIs with DRRs is a useful method in evaluation of inter-fraction reproducibility of tangential fields in breast irradiation, thereby improving upon the quality of treatment delivery for our patient population.

 > Abstract: 242: A prospective study to assess dosimetry and toxicity in postmastectomy hypofractionated radiotherapy in cobalt-60 teletherapy unit Top

Rajarshi Goswami, Bidisha Ghosh Naskar, Harris M. D. Sepai, Amit Saklani, Saurav Kumar, Souvik Paul, Suparna Kanti Pal

Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): To assess the feasibility in terms of Dosimetry and analysis of toxicity in Post Mastectomy Radiation Therapy using hypofractionated protocol in cobalt 60 teletherapy. In our setting many patients with breast cancer present to us for irradiation with limited resources that preclude the use of a long schedule of radiation. In a country with limited resources, a shorter courses of radiation with same efficacy is highly desirable. Materials and Methods: 30 post mastectomy patients with histologically proven invasive ductal carcinoma received Radiation Therapy which was delivered in doses of 42.5 Gy over 16 Fractions, 5 days per week, 2.65 Gy per Fraction, over 3 weeks in Bhabatron II telecobalt unit. All contouring were done following RTOG guidelines in Oncentra treatment planning system. Dosimetric analysis were done PTV max, Hotspot volume, Homogeneity Index, V20 Lung, Mean Lung Dose. Mean Heart Dose, V30 heart. Dosimetric Comparison between left sided disease with right sided disease was done. Echocardiography and PFT done before starting of radiation therapy and patients are assessed weekly for 3 weeks for skin and hematological toxicity. Then evaluated at the end of the treatment. At 6 months after completion of radiation, patients will be assessed for cardiological and pulmonary toxicity by clinical assessment and by performing Echocardiography and Pulmonary Function Test. Results: Mean age of the population is 48.36 yrs. 36.7% patients are in the age group between 41 to 50 years. 60% of the cases are of left sided tumor and 40% cases are of right sided. Mean hotspot volume is 0.19%, mean PTV max is 4703.13 CGy, mean homogeneity index is 1.16. The mean lung dose (CGY) (mean± s.d.) of patients was 976.8000 ± 244.2664. The mean V20 total lung (mean± s.d.) of patients was 21.60%±6.09%. The mean heart dose (CGY) of patients was 972.3000 ± 518.5553. The mean V30 heart of patients was 10.74% ± 9.7% In left side, the mean heart dose (CGY) of patients was 1340.6667 ± 300.4201. In right side, the mean heart dose (CGY) of patients was 419.7500 ± 119.6853. Distribution of mean heart dose (CGY) vs. side was statistically significant (p<0.001). In left side, the mean V30 heart (mean± s.d.) of patients was .1740 ± .0659. In right side, the mean V30 heart (mean± s.d.) of patients was .0074 ± .0100. Distribution of mean V30 heart vs. side was statistically significant (p<0.001). Distribution of mean lung dose (CGY) vs. side was not statistically significant (p=0.0696). Distribution of mean V20 total lung vs. side was not statistically significant (p=0.0668). 18 (60.0%) patients had skin toxicity G1, 8 (26.7%) patients had skin toxicity G2, 2 (6.7%) patients had skin toxicity G3 and 2 (6.7%) patients had skin toxicity G4. At 6 months follow up period no patients had symptoms of any radiation pneumonitis or cardiotoxicity. Conclusion: We have tried to assess the dosimetry and toxicity of the post mastectomy radiotherapy using hypofractionated protocol in Cobalt 60 teletherapy. The Study shows promising results in terms of dosimetry and toxicity analysis. But it is limited by many factors like small sample size and short follow up.

 > Abstract: 244: To study the dose to skin over tangential field with and without thermoplastic sheet and thermoplastic sheet with bolus in postmastectomy patients of carcinoma breast Top

Asmita Kulshrestha

Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Background: Breast cancer poses a major health concern due to its burden on women worldwide being the most common cancer. Postmastectomy radiation therapy (PMRT) forms an integral component in both breast conservation and patients to reduce the loco-regional recurrence and mortality rate. Purpose and Objective(s): Analyse the dosimetric parameters to skin over tangential field with and without thermoplastic sheet and with additional bolus in postmastectomy breast cancer patients. Materials and Methods: This study conducted from January 2017 to June 2018 in 20 postmastectomy recruited patients treated by radiotherapy using field-in-field (FIF) by three dimensional conformal radiotherapy (3D-CRT) technique alongwith planning by tangential fields and application of thermoplastic sheet was used to generate plans for the patients in all the three arms with same location chosen for all the depth dose profiles and compared for the dosimetric parameters. Results: The PTV coverage was significantly higher in plans with thermoplastic sheet with additional bolus followed by higher in plans for thermoplastic sheet (p- value <0.001) than in without thermoplastic sheet. The hot spot in the plans with thermoplastic sheet was significantly lesser (p-value <0.001) as compared to that in the other two plans. The depth differences for both 90% and 95% doses in the two plans of with and without thermoplastic sheet was statistically highly significant (p-value <0.001). The mean dose at 0.1 cm from the skin surface in the arm with thermoplastic sheet was significantly higher (p-value <0.001) than without the thermoplastic sheet. In all the plans with thermoplastic sheet with additional bolus whole skin in the treatment area was well covered with 100% dose. Conclusion: Thermoplastic sheet itself acts as a bolus to the chest wall surface for treatment planning ensuring homogenous dose distribution by achieving the required dose on surface along with adequate coverage of dermal lymphatics and postmastectomy scar, thus, reflecting an effective treatment response with minimal morbidity in patients of carcinoma of breast. Treating the patient without bolus on chest wall reduces the surface dose which is much smaller than that with bolus leading to a limited dose rate, thus a small thickness of the bolus material will lead to a significant increase in the surface dose.

 > Abstract: 260: Exploring the treatment controversies and finding balanced treatment of ductal carcinoma in situ Top

Sunder Singh, Abhishek Soni, Vivek Kaushal, Ashok Chauhan

Pt. B.D.S. PGIMS, Pt B.D.S. UHS, Rohtak, Haryana, India, E-mail: [email protected]

Background: Ductal carcinoma in situ (DCIS) is a non-invasive malignancy confined within the basement membrane of the ductal system of breast. With the widespread adoption of screening mammography, the incidence of DCIS has dramatically increased over the past 3 decades, from 1-2% to 20% of all newly diagnosed breast cancers. DCIS is associated with low rates of mortality irrespective of the treatment. Thus, outcomes are generally assessed in terms of recurrence. The basic treatment includes mastectomy or breast-conserving surgery (BCS) with or without radiation. Chemotherapy is not warranted. However, tamoxifen may be given as an adjuvant therapy. Purpose: Because survival after surgical treatment is excellent and neither RT nor tamoxifen therapy improves survival, there are concerns about the appropriate use of RT and endocrine therapies, each of which has potential morbidities. Therefore, significant controversy exists regarding the appropriate balance between risks and benefits of various treatments for DCIS. Methodology: Pubmed, Scopus, and Google Scholar were searched for publications related to DCIS, its controversies and treatment; and, relevant publications were included in the study. This review presents an overview of the current treatment approaches, its controversies and optimum use of management strategies for DCIS of the breast. Results: Mastectomy was once the gold standard for the treatment of DCIS; however, in current scenario, randomized trials provide consistent evidence that DCIS treated with BCS plus radiation compared with BCS alone results in reduced total local recurrence by 53% and local invasive breast cancer recurrence by 46% with no differences in overall and breast cancer mortality. These studies are frequently underpowered, subject to selection bias (patients are not randomly allocated to RT or not) and inconsistent in their control of known confounding factors. Studies demonstrated equivalent outcomes between BCS plus radiation and mastectomy, whereas BCS alone tends to be inferior to mastectomy. In the subset pools of these trials, lower level of evidence do not prove differential effectiveness of surgery versus radiation in the presence of some poor prognostic factors, like medium tumor size, multifocality, marked stroma, marked lymphoid infiltrate, or slight necrosis. This suggests that treatment may be important for patients with adverse prognostic features and treatment alone may not eliminate the adverse prognosis. Tamoxifen effectivity is based on a very small number of randomized studies but is quite promising. Although the relative benefit of tamoxifen is about 30%–50%, the absolute reduction is only about 2%–4%, which may not justify 5 years of endocrine treatment. The role of systemic treatments of DCIS needs further investigation. No effects on overall mortality or breast cancer mortality were seen. However, given the low level of mortality associated with DCIS and the long treatment horizon, it is likely that even the largest of these studies is underpowered to identify a mortality benefit. Conclusion: BCS plus radiation and mastectomy appear to yield equivalent outcomes, whereas BCS alone tends to be inferior to mastectomy. Tamoxifen seems helpful in treating DCIS. However, individualized therapy should be possible when future randomized controlled trials would be designed to detect differences in outcomes in patient subpopulations based on prognostic factors.

 > Abstract: 272: Scar boost following postmastectomy radiotherapy in skin positive breast cancer patients: A retrospective analysis of local control and skin toxicity Top

Shashank Shenoy, Rajan Yadav, Ankita Parikh, Suryanarayana Kunikullaya

The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): Additional radiation dose in skin positive (T4) carcinoma breast cases following mastectomy and PMRT (Post Mastecomy Radiotherapy) has been our institutional practice. There however have been criticisms pertaining to excess toxicity. This retrospective analysis aims to evaluate whether delivery of a chest wall boost (CWB) to the mastectomy scar/chest wall is independently associated with increased toxicity and to assess local control rates. Materials and Methods: We conducted a retrospective review of 167 breast cancer patients (T4 stage) treated at our centre between 2010 and 2015 who received additional radiation boost following mastectomy and PMRT (Post Mastecomy Radiotherapy) 50Gy in 25 fractions followed by 6-9 MeV electron boost to scar site 10Gy in 5 fractions. Primary objective was to evaluate the incidence of complications including skin necrosis, fat necrosis and infection. The secondary objective was comparison of the cumulative incidence of local failure. Results: Median age of the cohort was 49.3 years, all of them were T4 at baseline. The median follow-up was 6.5 years. Most clinicopathological features were well balanced between the 167 patients. 59.4% (99) were hormone receptor positive. The incidence of Grade 2, Grade 3, Grade 4 skin reactions, seroma and infection were 81 (49%), 36 (22%), 8 (5.1%), 12 (7.65%) and 2 (1.1%) respectively. The overall 5-year cumulative incidence of locoregional recurrence (LRR) was 3.3% for the entire cohort (95% CI: 2.5%-5.5%). Chest wall boost was not significantly associated with infection and skin necrosis. Conclusion: Our findings suggest chest wall boost in postmastectomy radiation increases skin toxicity, whether boost is associated with better local control rates needs to be evaluated in larger randomised, prospective studies.

 > Abstract: 284: Postmastectomy chestwall irradiation with electron beam technique: Analysis of outcome Top

J. S. Lakshmi, K. Beena

Amrita Institute of Medical Sciences, Kochi, Kerala, India, E-mail: [email protected]

Background: Postmastectomy radiation therapy (PMRT) reduces loco-regional disease recurrence but earlier trials failed to produce the survival advantage because of increased cardiac mortality. With the advent of modern techniques, PMRT related toxicities are reduced and of late translated into survival benefit. In our centre post mastectomy chest wall is routinely treated with enface electron using 6-8 Mev electrons, the advantage being reduced cardiac and pulmonary doses. Aim: In this retrospective study, we reviewed our PMRT electron beam treatment to evaluate the loco-regional control, toxicity and overall survival. Materials and Methods: The data of 450 patients who received PMRT with electron therapy from 2004-2014 were analyzed . All received 3DCRT technique using low energy electron 6 – 8 MeV to chestwall and 6MV photons to supraclavicular fossa (SCF) and medial axilla. CT based planning and appropriate electron energy and angle was decided depending on chest wall thickness and curvyness. Electron field is matched with the SCF photon field. Patients are followed up weekly during RT and every 3-4 months for the first 2 years and then 6 monthly for next 5 years and there after annually. Results: Patients median age was 64 yrs [range 24 - 74 yrs]. Performance score (KPS) of all the patients were above 80. Early stage accounted for 108 (24%) patients, 306 (68%) were advanced stage and for 36 (8%) patients stage was unknown. Of these, 174 (38.7%) patients were offered hypofractionated schedule and 276 (61.3%) with conventional fractionation. No grade 3–4 skin reactions were reported over the irradiated area on treatment completion. Twenty three (5.1%) patients had developed chestwall recurrence and 33 (7.3%) patients had developed loco-regional recurrence. Overall recurrence including systemic metastasis were 127 (28.2%). On subgroup analysis local, loco-regional and overall recurrence based on the fractionation schedules, there was no Statistical significance. Recurence based on stage, was found that 17 (3.7%) patients of advanced and 6 (1.33%) patients of early stage had local recurrence. Similarly 21 (4.6%) patients of advanced and 12 (2.66%) patients of early stage had loco-regional recurrence. Overall including systemic recurrences, 96 (21.3%) patients of advanced and 31 (6.8%) patients of early stage had recurrences, but no Statistical significance. No cardiac or pulmonary adverse events were recorded.

Median follow up of our group 67 months (6 – 173 months).

DFS at 5 years and 10 yrs were 81.4% and 79.5% respectively.

OS at 5 years and 10 yrs were 83.9% and 78.4% respectively.

On subgroup analysis, conventional fractionation were found to be associated with better OS. Conclusion: A single enface electron field is possible, and 3DCRT planning ensures homogeneous chest wall coverage, respecting dose constraints to organs at risk. The advantage of electron fileld is the better sparing of deeper structures, especially cardia in left sided postmastectomy irradiation, thus avoiding more complicated techniques like, IMRT, respiratory gating etc for cardiac sparing.

 > Abstract: 298: Impact of voluntary deep inspiratory breath-hold versus free breathing technique on heart and lung doses during radiation therapy for left-sided breast cancer Top

Deepti Sharma, Vineeta Goel, Nidhi Marjara, L. Nithiya, Ravinandran Gopal

MAX Superspeciality Hospital, Shalimar Bagh, Delhi, India, E-mail: [email protected]

Objective: Adjuvant radiation therapy to the whole breast or the chest wall is an integral part of the treatment of breast cancer. Long term cardiac morbidity is a concern with left sided breast/chest wall radiation treatment. This study is aimed to evaluate the impact of V-DIBH technique in reducing the heart and lung doses during radiation therapy of left sided breast or chest wall. Methods: Total 25 patients with left sided breast cancer were considered suitable for V DIBH from April 2018 – June 2019 at Max Hospital, Shalimar Bagh, Delhi. Patients were coached about the breath hold acquisition technique for 4-5 days before CT simulation. Breath?hold amplitude was monitored using Varian Real time Position Management (RPM) system comprising of perspex box with infrared markers as an external surrogate which is tracked by an infrared camera. Of the total cohort, six patients (24%) were non-compliant at coaching, therefore total of 19 patients underwent CT simulation in breath hold. Additional CT images were obtained in free breathing (FB) also. All 19 patients were treated with tangential IMRT techniques with V DIBH. For dosimetric purposes, radiation plans were also generated on FB scans. Target coverage and mean dose to organs at risk -heart, left anterior descending coronary artery (LAD), ipsilateral Lung and right breast were compared between the FB and DIBH plans. Results: Target Coverage was comparable in all patients in both FB and DIBH plans. When compared with FB, DIBH resulted in a significant reduction of mean cardiac dose from 5.7 ± 1.7 Gy to 3.4 ± 0.6 Gy (p<.05) and cardiac V25Gy from 7.3 ±4.1% to 1.6 ± 1.4% (p<.05). Heart volumes receiving low doses, V5 was 25.35±8.5% in FB group as compared to 15.8± 5% in DIBH group (p<.05). Mean dose to the LAD was 20.7Gy and 16.5Gy on FB and V-DIBH, respectively (p=.05). LAD D50 was 21.6Gy in FB group as compared to 15.3Gy in DIBH group (p<.05). Mean differences between FB and DIBH mean lung dose was 2.8 Gy (p=.11, ns) and ipsilateral lung V20Gy was 2.3% (p=.23, ns). Conclusion: This study demonstrates dosimetric benefits of V-DIBH over FB in reducing dose to heart, LAD and ipsilateral lung without compromising the target volume coverage.

 > Abstract: 300: Triple negative breast cancer – Are all patients having gloomy prognosis? A retrospective single institutional study in eribulin mesylate versus preeribulin mesylate era Top

Arnab Sinha, Bidisha Ghosh Naskar, Souvik Paul, Aloke Ghosh Dastidar

IPGMER and SSKM Hospital, Kolkata, West Bengal, India, E-mail: [email protected]

Background: Triple-negative breast cancer (TNBC) is defined by the lack of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER-2) expression. It consists of 20 to 25 % of all breast cancers and is an aggressive histological subtype which is associated with a higher incidence of recurrence and distant metastasis and a poor prognosis, whereas effective treatment strategies remain to be established. Resistance to current standard therapies such as anthracyclines or taxanes limits the available options for previously treated patients with metastatic TNBC to a small number of non-cross-resistant regimens, and there is currently no preferred standard chemotherapy. Duration of response is usually short, with rapid relapse very common and median survival of just 13 months. Purpose and Objective(s): To assess the benefit of Eribulin mesylate in Triple Negative Breast Cancer patients who have previously been treated with Taxanes and Anthracyclines in terms of Progression free survival. Materials and Methods: Eribulin mesylate 1.4 mg/m2 was administered IV on Day 1 & 8 of a 21 day cycle for 6 cycles in Triple negative breast cancer patients who have previously been treated with an Anthracycline or a taxane based chemotherapy regimen in metastatic or adjuvant setting and the Progression free survival was studied and compared with patients who were treated with other chemotherapeutic drugs. Results: 54 Triple Negative Breast cancer patients attended the Radiotherapy OPD of IPGMER & SSKM Hospital in 2017-2018 out of which 25 patients received an Anthracycline and Taxane based chemotherapeutic regimen in metastatic or adjuvant setting. 15 patients out of these showed progression of disease after treatment. 9 of these patients were administered Eribulin mesylate while the rest 6 were administered other chemotherapeutic regimen. Of the patients who received Eribulin mesylate, one patient (11.11%) expired while receiving treatment, one patient (11.11%) showed progression while on treatment two patients (22.22%) had disease progression within 8 months and rest of the 5 patients (55.55%) are still having stable disease (PFS>1 year). Out of the Rest of the 6 patients who were administered chemotherapeutic regimen without eribulin, 2 patients (33.33%) expired while on treatment, 3 patients (50%) had disease progression in less than 4 months' time and one patient (16.67%) is in stable disease for 12 months. Conclusion: Eribulin mesylate when used in Triple Negative breast cancer patients who have previously been treated with Anthracyclines and taxanes, improved 1 year PFS in patients as compared to patients who did not receive the drug. Hence it may be considered in case of TNBC patients who is resistant to Taxane and Anthracycline.

 > Abstract: 303: Dosimetric analysis of 1 week versus 3-week adjuvant hypofractionated radiotherapy using simultaneous integrated boost to the tumor bed following breast conservation surgery in the HYPORT adjuvant trial (NCT03788213) Top

Subecha Bhusal, Sanjoy Chatterjee, Santam Chakroborty, B. Silvamani, Patricia Solomon, Punita Lal, K. J. Maria Das, Rajesh Balakrishnan, Anurupa Mahata, Abha Kumari

Tata Medical Center, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): Hypofractionated adjuvant radiotherapy (RT) has become the standard of practice after breast conservation surgery (BCS). Fractionated tumor bed boost is well established to improve the local control in this setting. Also, recent studies have shown that simultaneous integrated boost (SIB) of 8Gy has similar toxicity to sequential boost of 16Gy/ 8 Fr to the tumor cavity in breast radiotherapy. We report a comparative analysis of the dosimetric data of patients treated with tumor bed SIB as a part of one week versus three week adjuvant hypofractionated radiotherapy post BCS, in the randomized phase III HYPORT Adjuvant Trial. Materials and Methods: Patients with non-metastatic, invasive breast carcinoma after margin negative resection (post BCS) with appropriate axillary staging who need adjuvant radiotherapy have been included in this analysis. Patients were randomized to either standard arm: 40 Gy in 15 fractions over 3 weeks to the whole breast +/- SCF RT or experimental arm: 26 Gy in 5 fractions over 1 week to the same volume. A hybrid tangent beam (TBSIB) plan incorporating volumetric arc therapy tok doses of 8 Gy in 15 fractions and 6 Gy in 5 fractions was used for tumor bed boost in the two arms, respectively. Sequential boost (12 Gy/4 #) was allowed in patients in whom surgical clips could not accurately delineate the tumor bed. In the standard arm, the mandatory dose coverage for tumor bed D98, D2cc (dose received by 98% of volume and 2cc volume, respectively) were set at ? 43.2 Gy, ? 51.4 Gy; whereas, in the experimental arm, D98, D2, were set at ? 28.8 Gy, ? 34.2 Gy. The mandatory mean heart dose (Dmean) constraints was kept at ? 2.5 Gy and ? 1.6 Gy for standard and experimental arms, respectively. All plans were generated using the Eclipse treatment planning system version 15.1 (Varian Medical System, Palo Alto, USA). Results: The trial opened for accrual on 28th March 2019 and 185 patients have been enrolled in the study till September 2019. Sixty four (34.6%) patients received adjuvant radiotherapy post BCS. Among these patients, 94 were in standard and 91 in experimental arm. Out of them, 58 (90%) patients received simultaneous integrated boost. The median conformity index of the boost plans was 1.68 (IQR 1.44-1.98) while the homogeneity index was 0.685 (IQR 0.57-0.84). The average D98 and D2cc was 45.61Gy and 48.98Gy respectively in the standard arm; whereas, in the experimental arm, the average D98 andD2cc were 30.25Gy and 32.73Gy respectively. The average heart Dmean was 0.66Gy in the standard arm and 0.64Gy in the experimental arm. Conclusion: Delivery of adjuvant radiotherapy post BCS, incorporating tumor bed SIB with both standard and extreme hypofractionated regimens showed adequate tumor bed coverage while strictly maintaining the normal tissue constraints.

 > Abstract: 311: Noble method of internal mammary nodal irradiation in locally advanced breast cancer using tomotherapy: A report on dosimetry and outcome Top

Samar Mandal, Sanjoy Chatterjee, Avipsa Das, Santam Chakraborty, Anurupa Mahata, Alice Louise Spencer, Isobel Alice Cathryne Pugh

Tata Medical Center, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): Use of adjuvant radiotherapy (RT) is standard practice in the treatment of primary breast cancer. Breast cancer can spread to internal mammary lymph nodes (IMN) which can be targeted in locally advanced tumors. IMN irradiation (IMNI) may result in delivery of high doses to the heart, lungs and contralateral breast due to their anatomical proximity. Any survival benefit gained from IMNI must be balanced against the risk of increased doses to normal tissues. Objective: To analyse the patterns of failure and RT dose delivered to target volumes and organs at risk in patients receiving adjuvant radiotherapy with IMNI for unilateral primary breast cancer, at Tata Medical Center, Kolkata. Materials and Methods: We included patients diagnosed with IMN metastasis on baseline imaging with PET-CT or CT thorax/abdomen. All were planned to receive intensity modulated arc therapy in Tomotherapy Hi-Art. Dosimetry data of the breast/chest wall and IMN clinical target volumes (CTV) and planning target volumes (PTV), plus organs at risk, was obtained from Tomotherapy treatment planning system and analysed with comparison to optimal and mandatory constraints. Late toxicity data at 6 months and/or most recent follow up were recorded. Results: 38 patients were included in the retrospective analysis. Adjuvant RT dose of 40Gy in 15 fractions over 5 weeks was delivered to all patients. Fifteen patients who had residual IMN on planning CT scan received an additional boost dose to the IMN of 10Gy (n=13), 12Gy (n=1) or 13.8Gy (n=1). After a median follow-up of 19.4 months, disease progression occurred in 3 (7.9%) patients (2 distant, 1 local). Average time to progression was 18.0 months. During phase one irradiation, average median dose delivered to the breast/chest wall PTV and IMN PTV was 40.58Gy and 38.43Gy, respectively. Average mean doses to the ipsilateral lung, contralateral lung and contralateral breast were 9.41Gy, 0.88Gy and 1.63Gy respectively. Regarding the heart, average mean doses were 5.23Gy in left-sided tumours and 2.02Gy in right-sided. Amongst all phase one plans, mandatory dose constraints for the ipsilateral lung (V18Gy<15%), contralateral lung (V2.5Gy<15%) and contralateral breast (mean dose<1.5Gy) were met in 36.84%, 100% and 47.37% of cases, respectively. In cases of left-sided tumours, 60.87% met the mandatory dose constraints to the heart (V13Gy<10%). On summating boost plans, the mandatory ipsilateral and contralateral lung constraints were met in 6.67% and 73.33% patients respectively and contralateral breast constraints in 53.33%. Heart constraints in left-sided tumours were achieved in 40% of patients. Late toxicity of heart and lungs was not recorded in any patient at 6 months or last follow up. Conclusion: Adjuvant RT to IMN resulted in encouraging local control rates in locally advanced breast cancer with IMN metastases. Doses delivered to normal tissues during IMNI often exceeded mandatory constraints, especially in patients receiving a boost dose to the IMN. However, this did not translate into late toxicities pertaining to the heart or lungs.

 > Abstract: 316: Risk factors in Indian female breast cancer patients: A single institute prospective study Top

Shreya Dwivedi, Aparna Suryadevara, Krishnam Raju

Pravara Institute of Medical Sciences, Loni, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): Breast cancer (BC) is the most common cancer in Indian females. The common risk factors for BC are nulliparity, age at first child birth >30 years, alcohol, red meat in the diet, not breast feeding, obesity after menopause, use of hormone replacement therapy, less or no physical activity which are more common in the western women than Indian women. According to literature about 30 to 50% of western women and only 18 to 20% of Asian women, with breast cancer have these risk factors which are modifiable and related to the lifestyle. The literature on this topic is sparse on Indian women. The purpose of our study is to evaluate Indian female breast cancer patients for the risk factors causing breast cancer at our institute., who were on treatment or follow up were evaluated by a questionnaire for risk factors causing breast cancer and analyzed. Materials and Methods: Biopsy proven breast cancer patients from March to September 2019 (n=200), stage I to IV, aged 20 to 80 years were evaluated by a questionnaire and analyzed. Results: Parameter (mean) Our study (n=200) Age at presentation- 49.5 yr (34% in 41-50 yr), Menarche (age)-13.2 yr (69% of pts for <= 13 y), (Age) menopause /Mean duration of menstruation (MDM)- 46.9 yr (77% women had menopause in <=55 yr), MDM- 256 month, Age of first child birth 20.9 yr (97% in <30 yr), Breastfeeding (% of cases) 'BF' -91%, Duration of BF -45.1 month, No. of children -2.37 (<= 2 children (57 %), Nulliparous-1%, Alcohol use-1%, Hormonal/infertility treatment 2%, Family history of breast cancer-11%, Height-5 ft (>=5 ft- 74%), Weight-61.3 kg (16% - 51 to 60 kg), Obesity after menopause (>5 kg)(OM)-12%. Literature from India Age-45.6 to 50 yr (21.3% in 50-54) Menarche (age)-13.5 yr (37.2% of pts for <=13 yr), MDM-341 months, Age at first child birth-52% for 21-30 yr, percentage of breast feeding-84%, No. Of children-58% pts had <=2 children, Nulliparous-7%, Alcohol use- 7% (in WHO data), patients with family history with breast cancer-5% (8-10% in WHO), height-5.11 ft, weight- 64 kg, Obesity after meno pause-39%. Conclusion: Our study results on risk factors for female breast cancer were comparable to other studies done on Indian women except for age at first child birth, nulliparity, alcohol use, obesity after menopause. These 4 risk factors were lower in our study patients. The limitation of our study is, that it is a hospital based study and needs a larger population based study to confirm the results.

 > Abstract: 321: Clinico-pathologic profile and loco-regional relapse pattern in triple negative breast cancer patients: An institutional study Top

Ghritashee Bora

Dr. B. Borooah Cancer Institute, Guwahati, Assam, India, E-mail: [email protected]

Background: Triple Negative Breast Cancer comprises 15-20% of all breast cancer cases. It refers to a breast cancer phenotype where Estrogen and Progesterone receptors are negative and also there is lack of over-expression of Her 2 neu by IHC. The biologic behaviour and clinical characteristics are different from Hormone receptor positive breast cancers. It is more prevalent in the younger age group, black race and in pre-menopausal women. They tend to be more aggressive with higher rates of local and systemic failure rates. Purpose of the Study: To study the clinic-pathologic profile of TNBC patients and determine their prognosis. Materials and Methods: This is a retrospective study where data was collected from the medical records of Breast Cancer patients registered at our institute between 2014 to 2016. A total of 80 patients were analysed for our study. Results: The median age group was 47 years, out of which 60 (75%) were <50 years and 20 (25%) were >50 years of age. 55% of the patients were of Stage III while 11% presented with metastasis. 83% of the non-metastatic patients underwent Surgery either in the form of MRM or BCS. High risk histo-pathologic features in the form of LVSI, ECE were present in 47% of the operated cases. 48% of the patients completed the planned course of treatment. Of the non-metastatic cases, 52% received RT while 47% did not receive adjuvant RT. The median follow up was 39 months. On last follow up, 5 patients died of metastatic disease and 28 patients had disease progression. Local relapse was seen in 8 of these patients and the loco-regional relapse free survival was 14.2 months. Conclusion: TNBCs are thus an aggressive disease with a rapid clinical course. Intense and longer follow up is essential for further analysis of this subset of patients.

 > Abstract: 322: Dosimetric study of adjuvant hypofractionated radiotherapy in carcinoma breast: How do the laterality of disease and extent of surgery effect the dosimetric profile to organs at risks? Top

Pritanjali Singh, Avik Mandal, Parveen Ahlawat, Dharmendra Singh, Manika Verma, Amrita Rakesh, Arka Sinha, Avajeet Kumar

All India Institute of Medicine Sciences, Patna, Bihar, India, E-mail: [email protected]

Purpose and Objective(s): Hypofractionated (HF) radiotherapy in breast cancer is steadily being adopted due to radiobiological advantages as well as less treatment duration and cost. This study is aimed to determine dosimetric safety of HF radiotherapy after BCS and MRM and to evaluate the effect of disease laterality on the doses to organs at risks (OAR) with 3D-CRT technique. Materials and Methods: This retrospective, observational study enrolled forty two patients of breast cancer who underwent either BCS or MRM and received HF radiotherapy to a dose of 40 Gy in 15 fractions over 3 weeks from February 2019 to July 2019. Patients were treated with 3D-CRT technique with appropriate photon beam energies on linear accelerator after simulation in supine position with breast board and free breathing. Treatment planning was done with 3D-CRT technique in Monaco treatment planning system version 5.11.02. Results: 11 patients were below 40 years age and 3 patients were more than 70 years. 22 patients were ER, PR positive and 16 patients were Her2 Neu positive. Laterality of the disease was almost equally distributed with 20 left sided breast cancer patients. 27 patients underwent MRM and rest underwent BCS. Pathological Tstage were pTx, pT0, pT1, pT2, pT3, pT4 were 7.14%, 4.76%, 9.52%, 38.1%, 28.57%, 11.9% respectively. pN0, pN1, pN2 and pN3 were 38.1%, 28.57%, 19.05%, 14.29% respectively. Supraclavicular region was treated for 80.95% patients. The mean D85%, D 90%, D95% to PTV Primary (chest wall/Whole breast) were respectively 3906.05 cGy, 3851.85 cGy, 3709.85 cGy for left side and 3873.55cGy, 3815.36 cGy, 3675.59 cGy to right sided breast cancer. The mean D85%, D90% and D95 % were 3876.04 cGy, 3823.78cGy, and 3678.48 cGy respectively for MRM and 3912.40 cGy, 3848.87 cGy, 3716.07 cGy for BCS respectively. No significant difference was found between right versus left sided as well as MRM versus BCS for PTV coverage. Between MRM and BCS, significant difference was found in conformality index (CI) but no difference was found for Heterogeneity index (HI). Mean of Heart Dmean, V16Gy, and V8Gy for left side were 347.845 cGy, 5.98%, 9.73% respectively and it was 97.71 cGy, 0.29% and 0.7% respectively for right side which is statistically significant difference (p<0.001). There was significant difference (p<0.044) of V16Gy ipsilateral lung dose between right and left sided breast cancer. Mean of V16 was 29.26 Gy and 25.44 Gy for right and left side respectively but no difference was found for V8Gy, V4Gy for ipsilateral lung and V4 Gy for contralateral lung. Interestingly, we found no significant difference of heart dose when compared BCS versus MRM. Mean of Dmean Heart dose, V16 and V8 to heart were 234.94cGy, 3.63%, and 5.87% for MRM respectively and 184.2 cGy, 1.87% and 3.44% for BCS respectively. No significant difference was found in lung dose parameters between MRM and BSC subsets. Conclusion: Dosimetrically safe constraints can be achieved with HF radiotherapy for both right and left sided breast cancer as well as after MRM and BCS. Left sided MRM patients are most critical subset to treat in terms of cardiac dose constraints.

 > Abstract: 323: Do any factors predict the magnitude of heart dose reduction with deep inspiratory breath hold radiation therapy in left breast cancers? Top

Ritika Harjani Hinduja, V. Kannan, Ranjeet Bajpai, Vivek Anand, Sudesh Deshpande, Suresh Naidu, Manasi Pendurkar, Prakash Umbarkar, Rohit Kabre, Priyanka Alurkar

P D Hinduja Hospital, Mumbai, Maharashtra, India, E-mail: [email protected]

Background and Purpose: Deep Inspiratory Breath Hold (DIBH) is a technique in Radiation therapy that has significantly led to reduction in radiation doses received by the heart while treating left breast cancers. It is now a widely accepted treatment for left breast cancers to decrease the long term cardiac morbidity. The purpose of this study was to identify physical parameters from the DIBH simulation scan that can predict the reduction in heart dose. Methodology: This is a retrospective study in which all consecutive patients of left breast cancer treated with breast conservative surgery and adjuvant radiation therapy using DIBH technique between 1st July 2018 and 31st December 2018 were included. Free Breathing (FB) and DIBH simulation image sets were available. Heart, left lung, Clinical Target Volume (CTV) and Planning Target Volume (PTV, PTV=CTV+5 mm) were contoured on the free breathing scan and Three-dimensional Conformal Radiation Therapy planning was done using tangents (and subfields where necessary). The DIBH amplitude obtained during simulation, the diaphragmatic movement between the two simulation image sets and ratio of lung volume in DIBH scan over lung volume in FB scan (Lung volume ratio- DIBH/FB) were compared to the reduction in heart dose. An attempt was made to study the changes in the position and shape of the heart. Results: Twenty patients treated for left breast cancer with DIBH radiation were eligible for the study. 18/20 (two patients' heart dose remained same) patients had a reduction in the heart dose with DIBH technique. The median reduction in the mean heart doses for the 18 patients was 36% (range: 11-57%). The median DIBH amplitude on simulation CT scan was 1.25 cms (0.9-1.5 cms). The median longitudinal diaphragmatic displacement between both image sets was 2.62 cms (-0.2 to 4.7 cms). The median of the ratio of Lung volume in DIBH images over FB images was 1.69 (1.51-2.48). There was no statistically significant correlation between DIBH amplitude or magnitude of diaphragmatic movement and reduction in the heart dose. There was a noted trend of increase in ratio of lung volume in DIBH images over FB images with reduction in heart dose (p-0.10). When the heart shape was analysed, there was a significant change in the transverse diameter of the heart. Subjectively, it was reported to be consistently more elongated and it most commonly had an anterior and downward shift. Conclusion: DIBH technique reduced the heart doses compared to those on free breathing scan as reported in literature. We could not demonstrate any physical parameters like DIBH amplitude, changes in lung volume or diaphragmatic movement that can predict reduction in mean heart dose. However, a trend was noted that there was higher reduction in heart dose as the ratio of the lung volume in DIBH over FB increased. A study with larger sample size may better quantify the results.

 > Abstract: 336: Cardiac doses in left side breast cancer patients with 3DCRT and conventional radiotherapy techniques: A comparative dosimetric study Top

Hima Bora

Dr. B. Borooah Cancer Institute, Guwahati, Assam, India, E-mail: [email protected]

Background: With the improvement in diagnostics and therapeutic techniques in treatment of breast cancer, overall survival of breast cancer patients is also increasing. Radiation induced cardiac adverse events are significant reasons for morbidity and mortality in long term survivors of breast cancer. Purpose of Study: In this study we are reporting the cardiac doses received by left sided breast cancer patients treated in our hospital with computed tomography (CT) simulation based bi-tangential conventional beam radiotherapy or by 3D-conformal radiotherapy. Materials and Methods: A total of 13 patients treated with left sided breast conservation surgery was selected for the study. CT simulation based bi-tangential plans and 3DCRT plans was generated for each patient for dosimetric evaluation. Results: In the 3DCRT arm, PTV coverage was found to be 94.74% vs 76.46 % in the TPS plan arm. The average Hot spot (V107%) was 105 cc in 3DCRT arm and 50cc in the TPS plan arm. In terms of dose to the OARs, the mean heart dose and the V20 of the contra-lateral lung was better in the TPS plan arm. Conclusion: Thus, 3DCRT results in better target volume coverage but at the cost of increased hot-spot and slightly inferior sparing of OARs.

 > Abstract: 338: Hypofractionated radiotherapy for breast cancer patients treated by breast-conserving surgery: Radiation therapy oncology group radiation morbidity scoring Top

Malhar Patel, Devang Bhavsar, Maulik Bhensdadia, Prapti Patel Desai

CIMS Cancer Center, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): To measure acute and late skin & subcutaneous RTOG radiation morbidity scoring in breast cancer patients undergoing breast conservative surgery followed by hypo-fractionated radiotherapy. Materials and Methods: Between February 2018 to August 2019, sixteen breast cancer patients, treated by breast conservative surgery followed by hypo-fractionated radiotherapy have been selected. Out of which 6 underwent oncoplasty during the breast conservative surgery. Three patients had breast cup size “D”. Thirteen patients had cup size “B”. Dose of radiation therapy was 42.5 Gy in 16 fractions followed by boost to tumour bed. Acute and late RTOG morbidity scoring for skin and subcutaneous tissue was calculated. Results: All sixteen patients are on follow up till date with average follow up of 8.18 months. Acute Skin Morbidity: Fifteen patients had grade 1 scoring; one patient had grade 2 scoring. Late Skin Morbidity: Nine patients had grade 0 scoring with average follow up of 11.6 months; seven patients had grade 1 scoring with 3.7 months of mean follow up. Acute Subcutaneous Tissue Morbidity: Two patients had grade 1 score; Fourteen patients had grade 0 score. Late Subcutaneous Tissue Morbidity: Two patients had grade 1 score; Fourteen patients had grade 0 score. Conclusion: As per our institutional data, hypofractionated radiation therapy in breast cancer treated by breast conservative surgery has acceptable early and late skin-subcutaneous tissue morbidity.

 > Abstract: 356: Dosimetric comparison between deep inspiration breath hold technique versus free breathing in the radiation treatment of left sided breast cancer patients Top

Ashutosh Mishra, Shagun Misra, K. J. Maria Das, S. K. Senthil Kumar, Punita Lal

Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, E-mail: [email protected]

Purpose and Objective(s): To document the dosimetric impact of Deep Inspiration Breath Hold (DIBH) Technique over Free breathing technique in the radiation treatment of left sided breast cancer patients and document the additional time required in deep inspiratory breath hold technique. Materials and Methods: 44 consecutive left sided breast cancer patients were screened and counseled for the study, 33 patients met the inclusion criteria who were accrued in the study, remaining 11 patients were excluded from study 5 patients were excluded in pre-simulation visit (2 phyllodes histology, 1 Asthma, 1 unable to hold breath and 1 scoliosis) and 6 patients were excluded at the time of simulation (3 irregular breathing, 2 metastatic, 1 unable to follow command from CT console). Dosimetric analysis was done for 30 patients (20 MRM + 10 BCS). Following counseling, and training, patients were made to practice breath hold for 20 seconds at home and once that was ensured patients were immobilized using either wing board or breast board. All patients had 2 sets of planning CT Scans (one in FB and another in DIBH). CT Scan in DIBH technique was performed by tracking the respiratory cycles using Varian Real-Time Position Management system. Target and organs at risk (OARs; Heart, LAD and ipsilateral lung) were delineated as per the RTOG (Radiation Therapy Oncology Group) contouring guidelines. Bi-tangential fields ± SCF field using single isocenter technique was adopted, radiotherapy to IMN is not being practiced routinely at our center. Field in field treatment plans were generated according to ICRU criteria using the Eclipse Treatment Planning System for both FB and DIBH CT images, and the doses to the target and OARs were compared. The Hypofractionated regimen of 40Gy in 15 fractions over a period of 3 weeks was used for chest wall and whole breast. 12.5Gy in 5 fractions were delivered to boost to cavity in BCS cases. Results: The target coverage parameter V95% received by PTV in BCS were found to be 97.55 ± 1.7 % in the FB plans and 97.51 ± 1.8% in the DIBH plans. Mean heart dose 2.14 ± 0.7Gy in FB plans and 1.44 ± 0.6 in DIBH plans. Mean LAD dose 11.5 ± 8.9Gy in FB plans and 4.46 ± 3.2 in DIBH plans. Mean ipsilateral Lung dose 7.76 ± 2.61Gy in FB plans and 6.1 ± 2.1 in DIBH plans. Mean IMN dose 18.05 ± 12.2Gy in FB plans and 14.4 ± 10.4Gy in DIBH. The time consumed in counselling, simulation and planning is 75.3 ± 5.4 minutes in FB and 110.3 ± 5.1 minutes in DIBH technique. Conclusion: Appropriate patient selection and adequate training is required in DIBH technique. There was a significant reduction in dose to the heart, LAD, ipsilateral lung and IMN in the DIBH plans compared to the FB plans. DIBH technique should therefore be considered for all suitable left sided breast cancer patients. However, this technique is time-consuming, requires patient cooperation and expertise.

 > Abstract: 381: Efficacy of capecitabine with WBRT in brain metastasis from triple negative breast cancer: A prospective randomised controlled trial Top

Pallavi Kalbande

MGIMS, Wardha, Maharashtra, India, E-mail: [email protected]

Background: Brain metastasis occurs in 21% of patients dying from breast cancer. Prognosis for brain metastasis is poor, with reported median survival of 1 month in untreated patients. Whole brain radiotherapy increases median survival to approximately 4-6 months. Triple negative breast cancer have a higher propensity for brain metastasis. Capecitabine is an oral fluropyrimidine carbamate approved to use in metastatic breast cancer. Oral capecitabine concentrates predominantly in tumour tissue and known radiosensitizer. It can cross the blood brain barrier. Purpose: To determine whether the addition of capecitabine along with WBRT improves response and survival in brain mets in triple negative breast cancer patients. Materials and Methods: 134 triple negative breast cancer with brain metastasis were randomly assigned to observation arm (n=65) and control arm (n=69. Patients in the observation arm received WBRT with capecitabine 825 mg/m2 during RT f/b 1250 mg/m2 every three weekly until progression or toxicity. Patients in control arm received WBRT. All patients were followed monthly. Primary endpoint for analysis were objective response rate, overall survival, progression free survival. All patients were treated with WBRT 30Gy in 10 fractions on 6 MV linear accelerator. Results: After treatment objective response rates in observation arm was 75.38% (49/65) was evidently higher in control arm 46.3% (32/69) with significant difference (p value<0.05). Median progression free survival was 8 months in observation arm and 6 months in control arm. Median OS was 10 months in observation arm and 7 months in control arm. Progression free survival and OS was significantly longer in observation arm (p value<0.05). Capecitabine was well tolerated with grade I nausea and vomiting in 53.84% (35/65). No neutropenia was observed. Conclusion: Capecitabine concomitant with WBRT is effective treatment in the management of brain metastasis in triple negative breast cancer in terms of local control and survival.

 > Abstract: 391: Hypofractionated radiotherapy with simultaneous integrated boost in advanced incurable breast cancer – Report on early clinical outcome and toxicity data of the HYPORT B study Top

Ritesh Santosham, Sanjoy Chatterjee, Santam Chakraborty, Anurupa Mahata, Samar Mandal, Abha Kumari, Avipsa Das

Tata Medical Center, Kolkata, West Bengal, India, E-mail: [email protected]

Background: Breast cancer is more sensitive to higher dose per fraction in view of their relatively low a/b ratio. In India, the incidence of advanced incurable breast cancer is more common than in the west, often necessitating palliative radiotherapy. However, the evidence regarding standard palliative breast radiotherapy schedule for such patients is sparse and often resource consuming. Hypofractionated regimes are therefore being investigated within this study. Purpose and Objective(s): To report the initial outcome and acute toxicity data of a single arm prospective study evaluating a 5 day hypofractionated external beam radiotherapy schedule with simultaneous integrated boost (SIB) in patients with advanced incurable breast cancer. Materials and Methods: Patients with locoregionally advanced incurable or metastatic breast cancer requiring palliation of local symptoms were enrolled in this prospective study. All patients received hypofractionated radiotherapy to a dose of 26Gy in 5 fractions over one week to the whole breast and ipsilateral supraclavicular fossa along with 6Gy SIB to the metabolically active tumour. Axillary nodes were irradiated only if involved. Acute toxicity was assessed using CTCAE version 4.03 toxicity grading criteria. Clinical response was assessed at 2 weeks and 3 months after completion of radiotherapy. Results: Nineteen out of thirty patients have been enrolled in this prospective study between April 2018 to August 2019. One patient had expired prior to the 3 month evaluation. Hence, we present our analysis on the remaining 18 patients. At presentation, 2 patients had breast related pain score above 5, 3 patients had bleeding from the tumour site and 5 patients had a fungating mass. 2 weeks after completion of radiotherapy, 4 patients (22.2%) had Gr II skin toxicity. None of the patients had acute toxicity or pain at 3 months, only one patient had persistent tumour bleed and one patient had a fungating residual disease. Clinical examination of the primary site done at 3 months showed that 10 (55.5%) patients had partial response (PR), 6 (33.3%) patients had complete response (CR) and 2 (11.1%) patients had clinical progression. Conclusion: Hypofractionated radiotherapy using this 1 week schedule showed acceptable toxicity and excellent palliation in advanced incurable breast cancer patients.

 > Abstract: 395: Hypofractionated whole breast irradiation in Indian scenario Top

Shambhavi Sharma, B. K. M. Reddy, Vinay Ural

North Western University, Evanston, IL, USA, E-mail: [email protected]

Introduction: Breast cancer is the leading cause of cancer mortality in women worldwide. The definite treatment of breast cancer is mainly Breast conserving surgery and various types of mastectomies with radiation therapy and chemotherapy as adjunctive treatment. While Conventional fractionation has been the standard of care since the advent of radiation therapy, Hypofractionated whole breast irradiation has evolved in over 2 decades and has proven to be equally effective despite concerns of late toxicity and cosmetic disfigurement. Purpose and Objectives: To compare the locoregional control, cosmetic outcome and skin toxicity of patients undergoing radiation therapy between conventional fractionated and hypofractionated regimes following breast conserving surgery. Materials and Methods: The study was a non-randomized observational prospective study conducted in patients treated at Apollo Cancer Centre, Bangalore who were treated with adjuvant radiation after breast conservation surgery. They were non randomly assigned to hypofractionated and conventional arms as adjuvant treatment. Photographs and breast measurements were taken of breasts prior to the commencement of radiation therapy and 6 months after completion of the treatment. Skin toxicity was evaluated at the end of radiation therapy, 3 months and at 6 months after completion of treatment, using RTOG toxicity scales. Locoregional control was assessed for 6 months. Statistical analysis was performed to compare the effect of radiation on breast cosmesis between the two groups. Results: The study had 56 patients (28 in each group). We found that the overall cosmesis score was equally distributed between both groups and there was no statistically significant difference between the groups. There was statistically significant change in all the measurements before and after treatment with the reduction in size. However this change was not found to be significant when the individual groups were evaluated or when the two groups were compared. In our study, skin toxicity at the end of radiation therapy, 3 months and 6 months post therapy was found to be equally distributed in both conventional and hypofractionated groups. The toxicity was not found to be different in the two groups (p> 0.5). The short-term survival and loco regional control was found to be 100%. Conclusion: We conclude that the cosmetic outcomes in the conventional and the hypofractionated groups are comparable. The toxicity scores in the two arms were comparable and not statistically significant. All patients had 100% loco regional control at the end of 6 months. Therefore, we suggest that hypofractionated radiation therapy to the whole breast is as effective as the standard conventional fractionation in terms of cosmesis and local control and can be safely practiced in an Indian scenario.

 > Abstract: 399: To compare axillary lymph node coverage in postbreast conservation surgery and postmodified radical mastectomy with 3-dimensional tangential field irradiation and correlation with heart and lung dose Top

Jyoti Mehta

M S Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose/Objective(s): (1) To compare the coverage of axillary lymph node with tangential breast irradiation fields in both arms by using virtual lymph node analysis. (2) Correlation with heart and lung dose with axillary coverage. Materials and Methods: 30 women who were treated with whole breast irradiation after breast-conserving surgery or Chest wall irradiation+ SCF were divided into 3 arms. The axillary and breast volumes were delineated according to the Radiation Therapy Oncology Group (RTOG) contouring atlas. The volumes of level I-III LN regions covered by 90% and 95% and 100% of the prescription dose (PD) were documented in both arms and correlated with the V20 ipsilateral lung and mean heart dose. Results: Level I LN mean and median volume (MMV) covered by 95% of the PD were 46.8% and 47.2%, respectively. MMV covered by 95% of the PD was 57% and 49 %. Mean and median dose to level I LNs were 76 Gy and 93 Gy, respectively in Post BCS arm. The MMV of level II LNs covered by 95% of the PD was 35% and 27%. The mean and median dose to level II LNs were Gy and 2.12 Gy, respectively. The MMV of level III LNs was 0% with a mean and mediandose of 1.04 Gy and 0.92 Gy, respectively. There was a moderate correlation between the 95% prescription coverage of level I LNs and V20 ipsilateral lung and a smaller correlation between 95% prescription coverage of level I LNs and mean heart dose. Distance from the humeral headwas inversely correlated with coverage of level I and II LNs and positively correlated with V20 lung. Conclusion: In this review of contemporary CT-based 3-dimensional conformal tangential breast plans, less than 50% of levelI LNs were covered by 90% of the PD and less than 30% were covered by 95% of the PD in the majority of patients. Mean (29 Gy) and median (30 Gy) doses to level ILNs were subtherapeutic. Doses to level II LNs were negligible, and doses to level III LNs were 0. There was amodest correlation between MHD and level I LN coverageand a moderate correlation between V20 ipsilateral lung and coverage of level I LNs, which suggests that increasing the prescription coverage for these LNs could increaseV20 ipsilateral lung. In this group of patients, a standard tangential radiation field did not provide significant therapeutic coverage of level I LNs and provided negligible coverage of level II and III LNs.

Abstract: 402: HYPOfractionated radiation therapy comparing a standard radiotherapy schedule (over 3 weeks) with a novel 1 week schedule in adjuvant breast cancer: An open label randomised controlled study (HYPORT-Adjuvant) (NCT03788213): Plan dosimetry analysis

B. Silvamani, Subhash Gupta, Sanjoy Chatterjee, Santam Chakraborty, Patricia Solomon, Punita Lal, K. J. Maria Das, Rajesh Balakrishnan, Anurupa Mahata, Abha Kumari, Subecha Bhusal

Tata Medical Center, Kolkata, West Bengal, India, E-mail: [email protected]

Purpose and Objective(s): HYPORT Adjuvant trial is a randomized phase III noninferiority trial comparing standard moderate hypofractionated 3 week radiation therapy to extreme hypofractionated 1 week radiation therapy. In a resource limited setting where radiation centers are overburdened with the unmatched increasing need, completing adjuvant radiation therapy to breast in 1 week over 3 weeks provides tremendous advantage. Primary Objective: Compare the 5-year locoregional recurrence rate (LRR) between arms. Any invasive recurrence in the ipsilateral chest wall/breast or ipsilateral regional nodes will be considered as an event. Secondary Objectives: Comparison of the overall survival rate (OS, 5 years), invasive disease-free survival rate (iDFS, 5 years), late adverse reactions (AE) and quality of life (QoL - measured using the EORTC QLQ C-30 and FACT-B questionnaires). Materials and Methods: Patients fulfilling the inclusion criteria were enrolled and randomized to either Standard arm: 40 Gy / 15 # / 3 weeks to the breast/chest wall with/without RNR or experimental arm: 26 Gy / 5 # / 1 week to the same volume. A hybrid TBSIB plan of 8 Gy (15 #) and 6 Gy (5 #) was used in the two arms respectively. TBSIB is planned using volumetric arc radiotherapy. Sequential boost (12 Gy/4 #) was allowed. A sample size of 2100 patients has been calculated. The trial opened for accrual on 28th March 2019 and 185 patients have been enrolled in meeting the target accrual rate. Comprehensive quality assurance of the treatment delivery process, dosimetry and dose delivery verification is being performed. Initial 185 patients dosimetric data were collected and analysed. Results: A total of 185 patients were enrolled in the study from two centers of which 94 were randomised to experimental arm of 5 fractions radiation therapy and 91 to standard arm of 15 fractions radiation therapy. The point dose variations of all the patients were collected which averaged to 0.48% (IQ range 0.04-1.59). The Ipsilateral lung, heart, contralateral breast received median doses of 4.75Gy, 0.56Gy, 0.11Gy respectively. Conclusion: The dosimetric constraints are well met in HYPORT Adjuvant trial, while ensuring adequate tumor bed coverage in both arms.

 > Abstract: 404: Quality of life assessment comparison between accelerated partial breast irradiation and whole breast irradiation in breast conserving surgery: A single institute experience Top

Vibhay Pareek, Rajendra Bhalavat, Manish Chandra

NCI, AIIMS, New Delhi, India, E-mail: [email protected]

Purpose and Objective(s): With proper case selection, Accelerated Partial Breast Irradiation (APBI) with Interstitial Brachytherapy has been an effective treatment modality and has been found to be non-inferior to whole breast irradiation (WBI) in terms of local control and overall survival. In our study, we present the results of quality of life assessment comparison between APBI and WBI in early breast cancer. Materials and Methods: Among the properly selected cases for APBI, the group was retrospectively compared with patients where similar indications for APBI persisted but refused the procedure. Quality of life assessment was done with EORTC-QLQ-C30 and BR23 questionnaires. The questionnaires were assessed at baseline, immediately after completion of radiotherapy, and during 3 monthly follow up. There were 24 patients who were treated with APBI and 26 patients treated with WBI followed by tumor bed boost. Results: Between August 2015 and June 2017, 50 patients were assessed. Ipsilateral local recurrence was considered as the primary end point and none of the patients achieved the same. The response to the questionnaire at the three phases of assessment was 100%. The results present the 2 year follow up evaluation of quality of life assessment in both groups. Global health status was found to be similar in both groups at baseline and at 2-year follow-up. Physical, Role and Cognitive functioning were also found to be similar. The significant difference was found to be in relation to Body image (difference of mean 12.8) and Breast Symptom function (difference of mena 13.8) in favor of APBI at 3 month follow up and non-statistical significant difference in systemic therapy side effects favoring APBI (difference of mean 8.1). Conclusion: Multi catheter Interstitial APBI with proper case selection in early breast cancer after breast conserving surgery, form a non-inferior treatment option with regards to local control and survival and is logistically simpler with few factors of improved quality of life.

 > Abstract: 424: To compare incidental axillary lymph node dose in postbreast-conserving surgery and postmodified radical mastectomy with 3 dimentional tangential field irradiation and correlation with heart and lung dose Top

Jyoti Mehta

Ramaiah Medical College Hospital, Bengaluru, Karnataka, India, E-mail: [email protected]

Purpose and Objective(s): Along with breast-conserving surgery (BCS) and Post MRM node positive cases, adjuvant radiotherapy (RT) of patients with early breast cancer plays a crucial role in the oncologic treatment concept. Conventionally, Breast irradiation is carried out with the aid of tangentially arranged fields. The use of this technique has implications for the incidental- and thus unintended- irradiation of adjacent loco regional lymph drainage in axillary lymph node levels I-III. (1) To compare the incidental dose of axillary lymph node with tangential breast irradiation fields in both arms. (2) Correlation with heart and lung dose with axillary coverage. Materials and Methods: Prospectively 30 women who were treated with whole breast irradiation after breast-conserving surgery or Chest wall + SCF irradiation were divided into 2 arms. Treatment was performed with a total dose of 40 to 50 Gy in 15 fractions with single dose of 2.6 to 3.3 ?Gy per fraction followed by boost to the dose of 10 to 12.5 Gy in 5 fractions to the lumpectomy cavity in post BCS cases using 3DCRT technique. The axillary and breast volumes were delineated according to the Radiation Therapy Oncology Group (RTOG) contouring atlas. The volumes of level I-III LN regions covered by 50% and 95% and 100% of the prescription dose were documented in both arms and correlated with the V20 ipsilateral lung and mean heart dose. Results: The mean volumes of axillary levels I, II, III, and total axilla were 28.3?±?6.8?cm3, 14.11?±?3.83?cm3, 5.7?±?1.5?cm3, and 48.8?±?9.5?cm3, respectively. The mean doses delivered to axilla were: 87% (73-98, ±4.8%) and 78% (range 67-90, SD ± 5.2%) level I (Post BCS vs post MRM; p = 0.042); 70% (46-83, ±12.4%) and 65% (29-87, ±11.8%) for level II; and 51% (28-76, ±11.1%), 53% (19-86, ±13.7%) and 41% (6-72, ±10.6%) for level III, respectively. V95 values (volume receiving 95% of dose) in both arms were 73% (65-80, ±3.4%) and 49% (43-53, ±2.7%) for level I (Post BCS vs Post MRM; p = 0.029); 41% (33-50, ±4.2%) and 25% (17-36, ±4.5%) for level II (post BCS vs Post MRM;p = 0.068); and 16% (10-24, ±3.7%) and 8 (5-12, ±3.1%) for level III (Post BCS vs Post MRM; p = 0.039), respectively. Conclusion: After the ACOSOG Z0011 trial, many clinicians treating breast cancer agreed to omit cALND for patients who meet certain eligibility criteria. They also focused on the incidentally irradiated dose to the axilla by WBRT as axillary levels I and II node receive substantial amount of incidental radiation doses in both arms which could be reason low locoregional recurrence rate in axillary nodes. Future studies will show wheather this has a incluence on loco regional spread in both arms.

 > Abstract: 426: Reduction of dose to the contralateral breast by use of lead shield in radiation therapy for postoperative Ca breast patients Top

Richa Verma, M. R. Athiyaman Mayilvaganan, Shankar Lal Jakhar, Neeti Sharma

SP Medical College and PBM Hospital, Bikaner, Rajasthan, India, E-mail: [email protected]

Introduction: Breast cancer is the most common cause of cancer in women in India. Surgery, radiation therapy and chemotherapy (+/- hormonal therapy) constitute the multimodality approach for treatment of breast cancer. Radiation therapy is recommended as a treatment of choice for post-operative ca breast patients. Radiation doses to nearby critical normal structures like heart, lungs, and contralateral breast (CLB) increases risk of second malignancies d. It appears prudent to be aware of these potential risk and efforts must be made to maintain a dose to CLB as low as reasonably achievable. In this study, we measured doses to the CLB and studied reduction in dose achieved by use of of a 2 mm lead shield. Materials and Methods: Ten post-operative Ca-Breast patients were taken for our study. All the patients underwent 3D conformal radiotherapy in Linear Accelerator (Make: Varian Medical Systems, Model: Clinac 2100CD) which has multileaf collimator 40 pairs. Forward IMRT Treatment plans were performed in Eclipse Treatment planning system (Make: Varian Medical Systems, Version 13.8) As the intent is to measure the contralateral breast dose the TLD discs (Type; CaSo4; Dy, 13 mm dia, 0.8 mm thick) were placed over the CB; Customized lead shields were prepared to study the reduction of dose to CB. Measurements were made with the TLD Discs with the presence and the absence of customized lead shield over the CB and doses were calculated with the help of TLD Reader (Make: Nucleonix, Hyderabad) Here we present a case of 10 ca breast patients who received radiotherapy post operatively. Radiation therapy of 40.05 Gy was planned in 15 fractions, 5 days a week, using the Eclipse Treatment Planning System version 8.9.15, with a pencil beam convolution algorithm and 6 MV photon beam. Plans were transferred to a linear accelerator (Varian 2300 CD) for execution of treatment. Twenty-four CaSO4 thermoluminescent dosimeter discs (TLDs) were used for dose measurement over the CLB. The dose was measured for each patient without a lead shield for 7 fractions and with lead shield for 7 fractions. Results: Mean doses/fractions received by the CLB without and with a lead shield were 12.62 ± 1.29 cGy and 6.42 ± 2.62 cGy, respectively, with total doses of 208.326 ± 32.43 cGy (5.14% of prescribed dose) and 113.7 ± 65.62 cGy (2.83% of prescribed dose). The average reduction in mean dose with a 2 mm thick lead shield was 53.10 ± 17.18%, in the range of 20 to 80% and statistically significant (p < 0.001). Conclusion: The above study was performed for 10 number of cases and it was evident in all the patients the dose to CB has reduced significantly. The lead sheets were customized for individual patients and it was an effective parameter in CB dose reduction. The lead sheets are in-house customized and can be easily made in every department with minimal cost. This study is further being extended for more number of cases with increment in lead thickness. We may find an optimum lead thickness that reduces significant dose to CLB without creating discomfort to the patient.

 > Abstract: 449: Is there any role of postmastectomy radiotherapy in node negative T1-T2 breast cancer patients? An institutional retrospective analysis Top

Tasneem Nalawala, Niketa Thakur, Ankita Parikh, Maitrik Mehta, Kushboo Jain

Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): To identify patient subsets with T1-T2 N0 M0 breast cancer at high risk of locoregional recurrence who may need consideration for postmastectomy radiotherapy. Materials and Methods: Medical records of 2 years from January 2013 to December 2014 were analyzed of patients of carcinoma breast who underwent radical mastectomy with pathologic T1-T2 N0 M0 with clear margins and those who did not receive adjuvant radiotherapy. Multiple factors were analyzed for risk of locoregional recurrence. Results: Total 350 patients were analyzed. Out of which 72 patients lost to follow up and 55 patients did not complete the planned chemotherapy and were excluded from the final analysis. The median follow up was 62 months. Out of the 223 patients included in analysis, 54 patients had local or nodal recurrence at a median interval of 11 months post treatment. 8 patients had distant metastasis at median interval of 45 months, of which 6 patients had triple negative breast cancer. In 54 patients who had locoregional recurrence, average age at presentation was 54 years, 42 patients had histologic grade 3 invasive ductal carcinoma, average tumour size was 4.3 cm, lymphovascular invasion was seen in 34 patients, average Nottingham Bloom Richardson score was 7, average closest margin was 0.4 cm away, average total lymph node dissected were 12 and 24 patients had triple negative breast cancer. Conclusion: This retrospective analysis showed that histologic tumour grade 3, presence of lymphovascular invasion, Nottingham Bloom Richardson score more than 7 and tumour size more than 4 cm are risk factors for locoregional recurrence in T1T2N0M0 breast cancer. Further prospective randomized analysis is needed for validation of role of postmastectomy radiotherapy in patients with these risk factors.

 > Abstract: 456: Response to neoadjuvant chemotherapy in various subtypes of breast cancer Top

Vaibhava Srivastava, Gaurav S. Mantri, Sonia K. Parikh, Asha S. Anand

Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): To evaluate clinical and pathological response, tumour resection rate and toxicity after neo adjuvant chemotherapy (NACT) in various subtypes of breast cancer. Materials and Methods: This was a single center prospective, observational study of response to NACT in various subtypes of breast cancer of duration around two years. Patients with definitive diagnosis of locally advanced breast cancer (LABC) as per AJCC 8th ed. and receptor status of estrogen (ER), progesterone (PR), human epidermal growth factor (HER2) by immunohistochemistry with/without fluorescent in-situ hybridization and planned for NACT were included. Carcinoma breast grouped into hormone positive HR+ (ER /PR + HER-), triple positive (ER /PR + HER +), triple negative (ER - PR - HER -) and HER2 positive (ER - PR – HER+). Planned for anthracycline/cyclophosphamide (AC) and of taxane (T) based chemotherapy with addition of transtuzumab (H) in HER2 positive cases if financially feasible. Demography, tumor stage and subtypes were studied. Clinical and pathological response (pCR) with resection rate after NACT and surgery was assessed and correlated with receptor status and chemotherapy regimen. Disease free survival (DFS) was obtained. Toxicity was assessed according to NCI CTC-AE v5.0. Results: 73 patients of LABC were studied. Median age was 48.8 years. Most common site was upper outer quadrant (65.3%). Most common feature was skin ulcers (47.9%) and satellite nodule (15.1%). N2 nodes were found in 56.2% cases. Of total 73 patients, HR positive 31 (42.4%), triple positive 15 (20.5%), triple negative 13 (17.8%) and HER 2 positives were 12 (16.4%). Four cycles each of AC and T based chemotherapy was received by 61 (83.5%) patients and H was received by 3 (11%) of all HER2 positive patients due to financial constraint. 66 out of 73 patients were available for clinical response evaluation, 7 patients were incompletely treated. Of 66 patients, overall clinical response (ORR) was seen in 95.4%, complete clinical response in 11 (16.6%) and partial clinical response in 31 (46.9%). Patients with stage IIIB disease had the maximum clinical ORR. Age and menopausal status were not found to have correlation with response. 59 out of 73 patients underwent surgical resection and pathological evaluation for tumor response was available for same, as in 11 patient's treatment was incomplete and was not available for pathological response evaluation and 3 patients progressed on NACT. In 66% of the patients tumor was down-sized. Pathological CR was observed only in 2 (8.6%) hormone receptor positive and 3 (23%) triple positive cases. Post NACT and surgery 59 patients were followed for 1-20 (median 6.2) months. 8 out of 59 patients developed relapse. TTR was in the range of 1-10 (median 3.6) months. DFS for the remaining 51 patients was in the range of 1-20 (median of 6.2) months. Overall NACT was well tolerated only 9% had grade 3-4 toxicity (mucositis and febrile neutropenia). Conclusion: Most common histopathological type was invasive ductal carcinoma. HR positivity was found in 42%, HER2 positivity in 16% and triple negative were 17.8%. Post NACT ORR was more than 90% with maximum in stage IIIB cases. The pCR rate was low 8.5%. Stage IIIB and hormone receptor.

 > Abstract: 463: Dosimetric comparison of intensity modulated radiation therapy versus 3DCRT in right breast cancer: Surrogate markers for potential intensity modulated radiation therapy candidates Top

Mridul Anand, Naveen Kanda, Ishu Sharma

Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): Intensity Modulated Radiation Therapy (IMRT) has been shown to reduce the dose to organs at risk for left breast cancer. However, IMRT has not been frequently employed in right breast cancer cases. The purpose of this study is to compare dosimetric parameters in women with early stage right breast cancer undergoing whole breast radiation therapy using 3DCRT and IMRT and to evaluate treatment planning and/or anatomical correlates for patients who may benefit from IMRT. Materials and Methods: An IMRT plan and 3DCRT plan was generated for 50 patients with locally advanced right breast cancer who underwent mastectomy and for whom post operative radiotherapy was indicated. The CTV and PTV were contoured according to the RTOG atlas and guidelines. PTV was prescribed 50 Gy in 25 fractions. Dosimetric and anatomic parameters like lung V20, maximum breast dose (Dmax), maximum skin dose (Dmax skin), chest wall separation (CWS) and medial gantry angle (MGA)) were determined for each paired treatment plan. Wilcoxon-signed rank test was utilized to compare IMRT and 3DCRT dosimetric parameters and Univariate analysis was used to identify planning or anatomic correlates associated with favourable dosimetric outcomes. Results: PTV V50 was higher for IMRT than that for 3D-CRT. IMRT reduces the Dmax skin, Ipsilateral lung V20, mean lung dose but a higher mean heart dose and mean contralateral breast dose was noted. Though no significant effect of CWS or MGA on any of the selected dosimetric parameters, a higher correlation was noted between CWS and mean heart dose and also between CWS and ipsilateral lung V20, both for IMRT. Conclusions: PTV coverage and lung V20 is superior with IMRT but the contralateral breast dose and mean heart dose are both higher with IMRT. This is clinically linked to the potential risk of secondary malignancies and cardiac toxicity. Chest wall separation is potentially a surrogate marker for patients who may benefit from IMRT versus 3DCRT, but further analysis with longer followup and higher number of patients is warranted.

 > Abstract: 465: Patient satisfaction survey for outpatient care in multidisciplinary breast cancer clinic Top

Akshay Mangaj, Tabassum Wadasadawala, Rima Pathak, Rajiv Sarin

Tata Memorial Centre, Mumbai, Maharashtra, India, E-mail: [email protected]

Purpose and Objective(s): To evaluate patients' satisfaction towards health care delivery system and identify factors to improve patient care delivery. Materials and Methods: A patient satisfaction questionnaire was developed and validated. Three hundred and thirty-nine breast cancer patients receiving active cancer directed treatment in outpatient clinicwere enrolled. Each patient had to complete 3 surveys: one each for surgical (SO), medical (MO) and radiation oncology (RO) professionals after their visits in respective OPDs. Results: The overall satisfaction score was 87.2% (IQR 80-100) for SO, 88.7% (IQR 82-100) for MO and 88.9% (IQR 88-100) for RO (p= 0.001). Overall, patients seemed to be more satisfied with RO as compared to SO and MO. In appointment and secretarial assistance (p=0.005) as well as in assisting medical staff and facilities (p = 0.031), patients were more satisfied with MO and RO as compared to SO. Overall, patients were prominently unsatisfied regarding the waiting times. The satisfaction regarding the treating physician as compared to type of the treatment was not found to be statistically significant (p=0.059). Of the various factors studied including socio-economic status, laterality, place of residence, education status and stage of disease, the satisfaction scores for patients who underwent SO (p = 0.025) and MO (p = 0.037) were significantly different for education groups.. Literate patients were the least satisfied regarding the waiting time. (p = 0.02) whereas illiterate patients were significantly (p = 0.008) least satisfied regarding the appointment and secretarial assistance in MO. Conclusion: Even though there was high level of overall satisfaction, there were difference in the satisfaction scores among various domains across SO, MO and RO out-patient clinics. Efforts must be driven towards improvement in above domains to further improve overall patients' satisfaction and health care delivery.

 > Abstract: 468: A treatment planning comparison of intensity modulated radiotherapy and 3DCRT for whole breast irradiation following breast conservation Top

Mridul Anand, Naveen Kanda

Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose and Objective(s): The radiation treatment for breast cancer has evolved from conventional wedged 2-D plans to more complex planning techniques like 3DCRT and IMRT with the intent of improving dose conformality and reducing dose to the organs at risk. Aim: This study was designed as a dosimetric study to compare the dose conformity and homogeneity to the PTV and doses received by the organs at risk using 3DCRT, IMRT and VMAT for whole breast irradiation following breast conservation surgery. Materials and Methods: IMRT and 3DCRT plans were compared for 50 female patients who received whole breast irradiation following breast conservation surgery treated at our center from July 2018 to July 2019. PTV was prescribed 50 Gy in 25 fractions at 2 Gy per fraction. The standard (RTOG) criteria was used for contouring the Breast CTV, PTV, and organs at risk. Dose volume histograms (DVH) were generated for both 3DCRT and IMRT plans and various dosimetric parameters such as Homogeneity Index (HI), Conformity Index (CI), dose to heart, both lungs, contralateral (C/L) breast were calculated. The p value less than 0.05 was considered as statistically significant. Results: Wilcoxon-signed rank test was utilized to compare IMRT and 3DCRT dosimetric parameters. The HI and CI were significantly better for IMRT compared to 3DCRT. The mean heart and lung dose were higher with IMRT compared to 3DCRT. There was no significant difference in the volume of heart receiving 30 Gy and volume of ipsilateral lung receiving 20 Gy between the two groups. The mean dose to contra lateral breast and lung were similar for IMRT and 3DCRT. Conclusion: Newer modalities of treatment aim to provide better PTV coverage with the reduction of organs at risk. The most significant effect is reduction in the Dmax., which may have an impact on the acute skin reaction and cosmesis. IMRT also increases the low dose region, while decreasing the high dose volume regions of ipsilateral breast and lung, which may lead to increase in the incidence of second cancers. Our study could not demonstrate any significant difference in the dose to organs at risk between the two modalities, so 3DCRT remains a valid option as a treatment modality in this group of patients.

 > Abstract: 473: Role of radiation in management of carcinosarcoma of breast: A single institution review Top

Sakina Mankada, Jyoti Poddar, Amit Kichloo, U. Suryanarayan, Ankita Parikh, Maitrik Mehta, Pooja Nandwani, Sonal Patel, Niketa Thakur

Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India, E-mail: [email protected]

Purpose: Carcinosarcoma (CS) of breast, also known as metaplastic breast cancer (MBC), is an extremely rare and highly aggressive tumor which accounts for <0.25 to 1% of all cases of breast cancers. We present a single institutional retrospective analyses of patients of CS, and discuss clinical presentation and their multimodality treatment approaches, and analyze the role of adjuvant radiation therapy (RT). Materials and Methods: Records of 61 patients diagnosed with CS of breast, who were treated at our institution from 2008 to 2014, were analyzed retrospectively. All patients included were treated with mastectomy with or without radiation. Chemotherapy was received by all patients as either neodjuvant or adjuvant form. Kaplan Meier analysis was used to estimate the overall survival (OS) and disease specific survival (DSS). Variables assessed included the patient age, histological subtype, T stage, nodal status, hormonal receptor status and use of RT. Results: Out 61 patients studied, RT was delivered to 29 patients (47.5%) and 32 (52.4 %) patients did not receive radiation. 5 Yr OS and DSS were statistically significant in patients who received adjuvant radiation than who did not (71.7 % vs. 55.3 % and 74.7% vs. 68.2). Conclusion: Our results show that adjuvant radiation treatment gives definite OS and DSS benefit in patients of carcinosarcoma of breast though these findings have to be confirmed in large prospective studies. Currently treatment strategies for CS has largely paralleled that of invasive ductal carcinoma (IDC) and specific treatment protocol for these not yet developed.

 > Abstract: 476: Multicatheter interstitial brachytherapy based accelerated partial breast irradiation – Dosimetric comparison with volumetric arc external beam radiotherapy: An observational study Top

Amina Beevi Shahabuddin, G. Kiron, Krishna Sharan, Anshul Singh, Stanley Mathew, V. Umesh, Sarath Nair

Department of Radiotherapy and Oncology, Kasturba Medical College, Manipal, Karnataka, India, E-mail: [email protected]

Objective: To dosimetrically compare multicatheter interstitial brachytherapy (MIBT) and intensity modulated radiotherapy (VMAT) for accelerated partial breast irradiation (APBI) with focus on dose to organs at risk (OARs). Materials and Methods: Twenty one patients with early stage breast cancer treated in the Department of Radiotherapy and Oncology, Shirdi Sai Baba Cancer Hospital, KMC Manipal during 2016-2019 with MIBT were selected for the study. For each patient an additional VMAT treatment plan was created using the same CT data and contours as used in MIBT plans. OARs included ipsilateral and contralateral breast, lung of both sides, skin, and heart. The CTV was created from the outlined lumpectomy cavity. The PTV in VMAT plans was generated from CTV with an addition of isotropic 5 mm margin. The prescribed dose was 34 Gy in 10 fractions for both techniques. From dose-volume histograms, quality parameters, tumour coverage, homogeneityincluding volumes receiving a given dose (e.g. V105, D95) and doses to specified volumes (e.g. V5, D0.01, D0.1, D1) were calculated and compared. Results: Mean ipsilateral lungdose was lower in MIBT, with D0.01, D0.1, D2 and V10 being statistically significant with D0.01, D0.1, D2, V10 being 63%, 59%, 47%, 24% in MIBT compared to 84.1%, 81%, 74%, 45% in VMAT plan. Heart doses were also lower in MIBT compared to VMAT, with D0.1, D2, and V10 showing statistical significance. D 0.1, D2, V10 for heart were 19.5%, 16.3% and 10% in MIBT respectively whereas it were 29.6%, 25.2% and 22% respectively with VMAT plan. Maximum dose received to skin was 93% in MIBT versus 81% in VMAT. Conclusions: The target volume can be appropriately irradiated by both techniques, but MIBT generally spares normal tissues and organs at risk better than VMAT. Whether this dosimetric benefit translates into clinical benefit needs to be ascertained.


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