Breast RNI and IMN coverage Discussion.... Again. Breast is the worst x 3?

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Sad thing is someone else will come in and offer spine sbrt, and no one will ever know how poorly it’s being done. Well maybe simul when they try to sneak in an sbrt charge for 20/5
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drowsy12 said:
Sad thing is someone else will come in and offer spine sbrt, and no one will ever know how poorly it’s being done. Well maybe simul when they try to sneak in an sbrt charge for 20/5
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Funny you say that

We actually check dose and fraction

Evicore only asks for fractions

My nurses are now doing BED calcs bc the GD skin cancer guidelines changed to pure BED.
 
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Just recycling as the title includes "breast is the worst," but does any one treat with the contralateral arm down? I do this for RNI with arcs for clearance purposes, but it also strikes me that even with tangents it would push the contralateral breast and probably heart lower/out of field. Maybe I'm behind the times.
 
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Ray D. Ayshun said:
Just recycling as the title includes "breast is the worst," but does any one treat with the contralateral arm down? I do this for RNI with arcs for clearance purposes, but it also strikes me that even with tangents it would push the contralateral breast and probably heart lower/out of field. Maybe I'm behind the times.
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Interesting thought.

i assume back in the old days, both arms were up to have reproducable positioning with skin markings?
But nowadays with surface guidance and CBCT…
 
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Ray D. Ayshun said:
Just recycling as the title includes "breast is the worst," but does any one treat with the contralateral arm down? I do this for RNI with arcs for clearance purposes, but it also strikes me that even with tangents it would push the contralateral breast and probably heart lower/out of field. Maybe I'm behind the times.
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In many centers this is routine. For patient comfort as much as anything else. I never treat patients on a “breast board” either. Just in vac locs. Not because I’m smart, or stupid. It’s just that’s how I was trained.
 
Palex80 said:
Interesting thought.

i assume back in the old days, both arms were up to have reproducable positioning with skin markings?
But nowadays with surface guidance and CBCT…
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Serious question, because I don’t treat breast but I cover my colleagues as needed. When treating nodes and the breast, how is CBCT better? I feel like often the body surface contour of the breast and the chest wall (etc) don’t deform in a uniform way and aligning to one takes you a little off on the other. I feel like personally, I would make sure to align to chest wall and use more flash to make sure the whole breast is treated. Breast is one place where often, I feel like port films show me what I need to know better than most other sites. I am sincerely curious from folks who do a lot of breast what the advantages are of CBCT for UNIlLATERAL non VMAT breast imaging? (Bilateral comprehensive plans are somewhat self explanatory).

And I am seriously surprised I am curious about breast. It is the WORST 😛
 
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My feeling is with more heavily modulated plans that are now more often forward imrt with ez fluence or reverse IMRT (even if they are mostly tangentially weighted fields with 4/6 static field arrangements), CBCT offers more precision, especially if you start dose painting a boost.
 
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ramsesthenice said:
Serious question, because I don’t treat breast but I cover my colleagues as needed. When treating nodes and the breast, how is CBCT better? I feel like often the body surface contour of the breast and the chest wall (etc) don’t deform in a uniform way and aligning to one takes you a little off on the other. I feel like personally, I would make sure to align to chest wall and use more flash to make sure the whole breast is treated. Breast is one place where often, I feel like port films show me what I need to know better than most other sites. I am sincerely curious from folks who do a lot of breast what the advantages are of CBCT for UNIlLATERAL non VMAT breast imaging? (Bilateral comprehensive plans are somewhat self explanatory).

And I am seriously surprised I am curious about breast. It is the WORST 😛
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CBCT, ExacTrac imaging, and surface guidance all work just fine.

I laughed out loud at the "case closed" smugness re: IMC treatment. Perfectly encapsulates where we are intellectually right now. What even is nuance?
 
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Entirely curious here - for your RNI IMRT/VMAT plans with CBCT guidance, what ptv margins are you using?
 
Ray D. Ayshun said:
Just recycling as the title includes "breast is the worst," but does any one treat with the contralateral arm down? I do this for RNI with arcs for clearance purposes, but it also strikes me that even with tangents it would push the contralateral breast and probably heart lower/out of field. Maybe I'm behind the times.
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It is reasonable to do with contralateral arm down or contralateral arm up. I personally prefer both arms up if patient can tolerate as it makes fusing previous treatment plans less painful if/when they require RT to the opposite breast but that's a very minor issue overall.

Some machines (like Halcyon/Ethos) are generally too small of bore to accomodate both arms up for majority of breast patients. But if on a standard TB or other Linac I'd probably favor both arms up.
 
taserlaser said:
Entirely curious here - for your RNI IMRT/VMAT plans with CBCT guidance, what ptv margins are you using?
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I just follow NSABP B-51, which is 7 mm for chest wall and 5 mm for nodes. Those are also cropped in various ways as per protocol. It's complicated and weird bc breast is the worst, but I've had 0 LRRs in 4 yrs....
 
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taserlaser said:
Entirely curious here - for your RNI IMRT/VMAT plans with CBCT guidance, what ptv margins are you using?
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7mm

I do both arms up. I've seen both one arm and both arms up, and I think both arms up is more comfortable for the pt.
 
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Banner told us that Houston does both arms up and I ended up asking why.

The reason I was told ... "In case they develop a contra cancer, it will be easier to treat"

That's ... a reason.
 
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RealSimulD said:
Banner told us that Houston does both arms up and I ended up asking why.

The reason I was told ... "In case they develop a contra cancer, it will be easier to treat"

That's ... a reason.
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If you're willing to advance an argument like that, a rejoinder is, contra arm down, they're less likely to develop one.
 
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I'll be out back..

sausage cooking GIF
 
1699292622700.png


#RNIsaveslives


TheWallnerus:
Trigger GIF by MOODMAN
 
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"In the eight older trials (2157 patients), which started during 1961–78, regional node radiotherapy had little effect on breast cancer mortality (RR 1·04, 95% CI 0·91–1·20; p=0·55), but significantly increased non-breast-cancer mortality (1·42, 1·18–1·71; p=0·00023), with risk mainly after year 20, and all-cause mortality (1·17, 1·04–1·31; p=0·0067)."

But, how do you square this?

Those were old trials. In the last 20 years we've made great strides with technology and technique so....

But... with risk mainly after year 20...?

Fuggetaboutit.
 
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TheWallnerus said:
This means you must give ENI to T1N0, or at least it’s now a supportable standard of care. I definitely could not see that one coming.

Also I feel bad for all the women radiation killed prior to the 1990s.
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I can't even get a surgeon to perform a SLNBx in cN0 patients. Now, you want me radiating all the LNs in all these patients?

Sounds reasonable.
 
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Mandelin Rain said:
I can't even get a surgeon to perform a SLNBx in cN0 patients. Now, you want me radiating all the LNs in all these patients?

Sounds reasonable.
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And you sure can’t get them to dissect an axilla in a SLN+ patient (and we know positive lymph nodes are left behind in the patient from not dissecting). We didn’t even need a meta-analysis to know that not dissecting out those left behind positive nodes actually doesn’t affect outcomes at all. BUT… this meta-analysis says we can affect outcomes if we irradiate the axilla, sclav, and IMNs. Which in and of itself is not a new finding, but saying it affects survival for a single node positive patient kind of is new. And saying it improves survival in N0 is really new; that actually does conflict with previous trial outcomes (the “power” of meta-analysis finds things trials didn’t).

For a lot of breast rad onc, the way you treat will depend on which conflicting high level data point you want to grant primacy in your decision making.
 
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I'm not doing RNI for T1N0 patients.. ever.

By the time we realize "This is a bad idea" some new immunology drug will have cured all of it. And women won't have had increased heart/lung exposure for marginal, if any, gainz.
 
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Palex80 said:
Tripple negative, 1.9 cm, G3, Ki67 80%, upper inner quadrant with extensive LVI, cN0 pNx?
Hit It GIF by America's Got Talent's Got Talent
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What do you mean by pNx? I would definitely not do if CR to chemo; those triple negative patients do great long term. But, no, I will not do ENI for any cN0/pN0 patient. AFAIK, there is no cN0/pN0 presentation for which the NCCN would recommend ENI. We don't mention that the most significant differences between ENI and no ENI in MA20 and EORTC were in side effects. (Woops, just mentioned it.) Axillary lymph nodes are not waystations to distant metastasis, especially in your hypothetical case.

Now, take everything I'm saying with a grain of salt given this "compelling" recent meta-analysis. For if you want ENI for a T1cN0 triple negative, you would want ENI for T1cN0 ER+... it would just logically follow, based on this fused, melded, data (as long as you discard some of the old data).
 
TheWallnerus said:
What do you mean by pNx? I would definitely not do if CR to chemo; those triple negative patients do great long term. But, no, I will not do ENI for any cN0/pN0 patient. AFAIK, there is no cN0/pN0 presentation for which the NCCN would recommend ENI. We don't mention that the most significant differences between ENI and no ENI in MA20 and EORTC were in side effects. (Woops, just mentioned it.) Axillary lymph nodes are not waystations to distant metastasis, especially in your hypothetical case.

Now, take everything I'm saying with a grain of salt given this "compelling" recent meta-analysis. For if you want ENI for a T1cN0 triple negative, you would want ENI for T1cN0 ER+... it would just logically follow, based on this fused, melded, data (as long as you discard some of the old data).
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I meant no SLNB performed.

I believe TNBC patients benefit more than luminal A from RNI.
 
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TheWallnerus said:
Axillary lymph nodes are not waystations to distant metastasis, especially in your hypothetical case.
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If you look at the subgroup analyses from this meta-analysis, the benefit from RNI was lost when the IM nodes were not irradiated. Maybe it’s really the IMNs that matter the most for RNI. DBCG would support that
 
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Also, overall mortality benefit as no detriment to rni in modern cohort. I am almost certain it’s clearance of imn seeding distant disease.
 
If the region LN don't getcha, the CVD will.. so sum zero.

I'm just not gonna do IMN for everyone except those with UIQ, or radiographic evidence. Would some sneaky MRI format help?

Maybe we need to figure out a way to do IMN biopsies with less trauma.

I dunno.
 
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