Difficult breast cases (what's your technique?)

[drnick098]

How would you treat these using basic techniques (not proton / tomo / electron arcs)? What is your patient positioning and treatment technique? I've google image searched some representative pics for each case.

Case 1: 48 year old woman with a neglected, fungating breast cancer and large axillary nodes causing problems with arm movement (can't get arm above head).

Case 2: 55 year old woman with past history of IDC, having undergone a left modified radical mastectomy 3 years ago, presenting with multiple chest wall nodules, extending from left anterior chest wall, wrapping around into the axilla, and into the left back. No previous RT.

I'll post my take on these later.

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[Palex80]

I'd use IMRT for that, more or less a half rotational technique with 7-9 step-and-shoot fields. Dose would me 50.4-54 Gy in 1.8-2Gy/d.
I don't see the chance of being able to boost anything, perhaps in case of good remission you could boost some left-overs after completion of RT.
Combination with capecitabine or vinorelbine is an option as well.

 

[Neuronix]

How would you treat these using basic techniques (not proton / tomo / electron arcs)?

How basic? Are you going for the "What would you do in Africa" scenario where you don't have MLCs or only have a cobalt tube?

I wanted to say tomo, but now I'll just say VMAT with 1cm bolus to the skin nodules. Supine, arms up in a wing board. Some type of hypofractionation, of which there are many different reasonable combinations of fractions and doses, is fine given the palliative intent. Of course they'd need other staging (I'd recommend PET/CT and brain MRI), further chemo, and they're very likely to have disease elsewhere that will limit their life expectancy.

 

[drnick098]

Thanks for your input guys. Ok here's the scenario You have a basic linac that has MLCs and you can do conventional photon / electron techniques. You can do IMRT but your dosimetrists will tell you that they don't know how to plan anything that's not a prostate or a head and neck so you'd have to do it yourself. Oh yeah and what's your arm positioning and immobilisation for these patients?

Case 1:
Main challenge is how to treat this with the arms down. I've never done this, but this is how I'd imagine doing it:
Patient supine with left arm taken as far lateral as possible without causing discomfort, and clearing the CT bore, immobilised in a vacuum bag. Bolus all of the areas fungating through the skin.

Basically a big AP/PA SCF and axillary field, angled slightly oblique to get more breast tissue but not shooting through her arm or excessive lung with 6MV photons.
Borders: sup: cricoid; inf: 3cm below the lowest extent of breast / GTV; lateral: 3cm lat to gross axillary node; medial: pedicles
Shielding: 1cm within ribcage to shield out the lungs on the posterior beam only (leaving the ant one to treat the breast - possibly with MLCs/block shielding the upper inner quadrant where there's less tissue to get through)
Supplement the ant beam with ant-oblique electron patches of various energies to treat the thickness of the GTV without exceeding lung constraints.

Say if she's fit with low distant disease burden, I was thinking high dose - something like 50Gy + 10Gy boost to gross disease at 2Gy per fraction.

Case 2:
(If she can get her arm up)
Patient in right lateral decubitus, with left arm up, immobilised in a vac bag. Bolus all of the nodules.
Treat with 3 electron patches (ant, lat, post) with 6MeV

Again if she's fit with low distant disease burden, I was thinking 50Gy at 2Gy per fraction.

Thanks guys! I'd be interested to hear your thoughts about these.

 

[Palex80]

Case 1: I fear lung dose will be limiting. I don't see you being able to give that much dose with such a technique. You are probably looking at the 70-80% isodose in large parts of the whole left lung.

 

[clinonc]

Case 1: if the disease is ER positive she should be treated with hormone therapy to maximal response, which will hopefully allow greater abduction of the arm and allow you to treat with tangents and a matched SCF field to 36 Gy in 6 over three weeks (30 in 5 to the SCF). If the disease is ER- then it's likely to have such a poor prognosis that the treatment would be aimed at palliation of the areas that have eroded through the skin only with electrons using a hypofractionated regime (e.g. 20 Gy in 5). Delivering daily RT over five weeks would likely be futile if ER-.

Case 2: she has extensive cutaneous metastatic disease. I would again question the wisdom of a prolonged course of RT, as she is likely to relapse almost immediately outside the treatment field. She should receive systemic therapy, and electrons or orthovoltage photons to treated particularly symptomatic areas.

 

[drnick098]

Case 1: I fear lung dose will be limiting. I don't see you being able to give that much dose with such a technique. You are probably looking at the 70-80% isodose in large parts of the whole left lung.

Fair enough. Only other technique I can think of is to treat through the arms with tangents / some kind of IMRT.

Case 1: if the disease is ER positive she should be treated with hormone therapy to maximal response, which will hopefully allow greater abduction of the arm and allow you to treat with tangents and a matched SCF field to 36 Gy in 6 over three weeks (30 in 5 to the SCF). If the disease is ER- then it's likely to have such a poor prognosis that the treatment would be aimed at palliation of the areas that have eroded through the skin only with electrons using a hypofractionated regime (e.g. 20 Gy in 5). Delivering daily RT over five weeks would likely be futile if ER-.

Say she's ER+/PR+/HER2- but only gets minimal disease response with a couple of lines of endocrine tx. These lesions took 10 years to get to the current size and she just hasn't sought medical attention. The only other disease she has is 3-4 asymptomatic rib and thoracic spinal mets. She still can't get her arm above her head, and she's still getting significant pain in most of her breast and the axillary node. The surgeons aren't keen to do anything.

Basically, I'm after how do you treat a breast without the arms up.

Case 2: she has extensive cutaneous metastatic disease. I would again question the wisdom of a prolonged course of RT, as she is likely to relapse almost immediately outside the treatment field. She should receive systemic therapy, and electrons or orthovoltage photons to treated particularly symptomatic areas.

Fair enough with the dose. Say she's ER+/PR+/HER2- and no distant mets - all of her disease is on her left chest wall (ant, lat, post). These have been slowly growing over the last 12 months. You try a few lines of endocrine therapy over the next 3 months with minimal response, but no new disease popping up elsewhere. A few of these are close to fungating through the skin.

Basically, I'm after how do you treat a chest wall wrapping around the back without going to rotational techniques / IMRT.

 

[Palex80]

Basically, I'm after how do you treat a breast without the arms up.

You put the arms down.