Breast IMRT

[deleted4401]

Interesting editorial. Basically saying that breast "IMRT" is really just tissue compensation, and it's inappropriate to bill as IMRT, but since there is no intermediate code or 'levels' of IMRT, people are billing it as true IMRT.

http://www.practicalradonc.org/article/S1879-8500(13)00132-X/fulltext

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[medgator]

Interesting editorial. Basically saying that breast "IMRT" is really just tissue compensation, and it's inappropriate to bill as IMRT, but since there is no intermediate code or 'levels' of IMRT, people are billing it as true IMRT.

http://www.practicalradonc.org/article/S1879-8500(13)00132-X/fulltext

It is something I've thought about too. Inverse vs forward planning. Essentially those positive trials for "breast IMRT" were really looking at FinF/EComp techniques, rather than true inverse planned IMRT.

 

[user_name]

I recently had a difficult case with reconstructed chest wall with expander in place (some deflation) and prior contralateral breast RT that crossed midline. Our facility uses FIF (forward planned IMRT) for breast. I thought we should give IMRT a try just to see in this case. We tried to hybrid techniques described in numerous recent Red J articles with fixed tangents supplying most of the dose and then adding IMRT fields to the "base plan" to improve dose. It was further complicated by needing SCLV fields. Some of the problem may be our inexperience, but I was not impressed with the results. FIF did just as well (really better in our hands) than some portion IMRT. We did not try all IMRT due to my unwillingness to do six fields spilling into lungs and contralateral, previously treated breast.

A few years ago (3?), Dr. Haffty at Radium meeting in Vancouver said he was doing "IMRT" and recommended for all patients but would not bill for it during his talk. I approached him afterwards and he clarified that he was doing forward planned segments. Not sure how he feels now.

 

[Reaganite]

I recently had a difficult case with reconstructed chest wall with expander in place (some deflation) and prior contralateral breast RT that crossed midline. Our facility uses FIF (forward planned IMRT) for breast. I thought we should give IMRT a try just to see in this case. We tried to hybrid techniques described in numerous recent Red J articles with fixed tangents supplying most of the dose and then adding IMRT fields to the "base plan" to improve dose. It was further complicated by needing SCLV fields. Some of the problem may be our inexperience, but I was not impressed with the results. FIF did just as well (really better in our hands) than some portion IMRT. We did not try all IMRT due to my unwillingness to do six fields spilling into lungs and contralateral, previously treated breast.

A few years ago (3?), Dr. Haffty at Radium meeting in Vancouver said he was doing "IMRT" and recommended for all patients but would not bill for it during his talk. I approached him afterwards and he clarified that he was doing forward planned segments. Not sure how he feels now.

I work in a population with lots of obese women with huge hearts, and I've done IMRT on several left sided breast tumors where the lumpectomy cavity is basically adjacent to the heart. I have actually been very happy with the dosimetry. We typically use 5 beams, 4 of which are essentially tangential. I constrain lung hard, and have not had a problem meeting V5,10, and 20 constraints from the most recent breast RTOG protocol.

 

[deleted4401]

What angle does the 5th beam come in from? That's the cases we do it, in, too - for IMN or if lump is posterior. But, I still have discomfort with non-tangential beams for breast cancer. I don't know, just seems to hard to assure reproducibility. What sort of constraints are there for lung?

 

[deleted4401]

Well, recently, I saw a patient with multiple positive LNs and their surgeon was from Hopkins so they also saw the radonc at JHH, who said "Make sure SimulD treats the IMNs," and it wasn't unreasonable, so to avoid conflict with referring physicians, I did it. I usually do it in the cases you mentioned. But, partner is doing it more often in locally advanced cases, basing this on MA.20 and the old PMRT trials. I don't know. Too much discordance within literature right now with this.