Hypofractionate or no?

[Mandelin Rain]

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47 yo s/p left lumpectomy with oncoplastic reconstruction and contralateral reduction for left sided DCIS

Left breast ended up having multifocal grade 2 invasive ductal ca, largest 8mm, ER+ PR+ arising in EIC. 0/2 nodes. Questionable margins with positive anterior, that was though to be excised with oncoplastic procedure.

Right breast with incidental (negative pre-op mammo and MRI) DCIS in reduction specimen with margin positive at cautery.

The left tumor bed is clipped, but the right is certainly not.

Has had some wound healing issues that have delayed her care. Recommended to bilateral mastectomy by surgeon, but refused. Will get hormonal therapy.

Now sent to me for XRT. Assuming she's adamant about conserving breast, what dose/fraction schema to each breast? I'll boost the clips on the left, but try to boost something on the right?

 

[Burt Radnolds]

Yeesh...

I would hypofractionate as I don't see a clear reason not to (and tend to believe it has less toxicity, per most data). That's probably the easiest to answer question regarding your situation.

I think the nature of the questionable and/or positive margins are potentially informative. If its a focally positive margin, there is data from the Netherlands to suggest that it might not matter much

Omitting re-excision for focally positive margins after breast-conserving surgery does not impair disease-free and overall survival

Focally positive margins in breast conserving surgery: Predictors, residual disease, and local recurrence. - PubMed - NCBI

I agree with boosting both sites. Boosting in the setting of oncoplasty is unsettling and I often choose not to unless a Biozorb was placed or the surgeon intentionally well clipped the area. However, she is young and has questionable margins. If the specimen is oriented or there is an area that is visible on retrospect in preop imaging, it may guide you. Worst case scenario is you try your best and miss. If you truly have no clue where this DCIS was on the right, then maybe you don't boost.

I usually use 4005/15 + 1000/5, but in cases such as yours where I have a bad vibe, I use 4256/16 with 1000/4 as it packs slightly more pop. I probably wouldn't boost higher than that given the area might be somewhat large.

 

[nkmiami]

as mentioned above, not all margins are "equal", especially focal anterior one. Number of papers on this.

 

[evilbooyaa]

young patient, would boost L sided IDC. 42.56 + 10Gy boost. Do 16 if you're really anxious and can localize well, otherwise 10Gy to a larger area.

right breast would favor some sort of attempt at re-excision. If impossible then boost something. Likely discussion with plastic surgeon of exactly what they did during the contralateral reduction.

No reason to omit hypofractionation in this scenario IMO.

 

[OTN]

I would feel ok hypofractionating.

French data suggests no need to re-excise +DCIS margin- 16 Gy boost appears to be able to overcome.

 

[Palex80]

Hypofractionate both sides 39.9/2.66 or whatever else you are doing for hypofractionation + boost. Both sides with 16/2 seems reasonable.
IBCSG 38/10 has recruited 1600 patients and randomized DCIS with risk factors to boost or no boost. Results are pending since the trial closed 4 years ago.
Patients were treated with hypo- or normofractionate for the WBRT, so we should get info on fractionation for DCIS from that trial too.
IBCSG 38-10 (TROG)

 

[SneakyBooger]

Sounds high risk in a young woman.

4500 at 180 f/b boost to lump site(s) of 1620 at 180.

 

[mavrik13]

No reason not to hypofractionate. Agree with 42.5/16 with 10/5 boost given thought the margin was revised at oncoplastic procedure (otherwse would offer 16/8 boost).

Would strongly recommend reexcision of DCIS in the right breast (repeat lumpectomy). There is no telling how much DCIS is hiding in there given it is occult disease on imaging, and would not feel comfortable with RT alone controlling DCIS long-term even with a boost.

Certainly sounds like she needs genetics referral too.

 

[xrthopeful]

Sounds high risk in a young woman.

4500 at 180 f/b boost to lump site(s) of 1620 at 180.

7 weeks of radiation?

wow.

 

[SneakyBooger]

How many in the USA using hypofractionation for regional lymphatics?



1. Int J Radiat Oncol Biol Phys. 2018 Oct 23. pii: S0360-3016(18)33897-5. doi:
10.1016/j.ijrobp.2018.10.014. [Epub ahead of print]

Contemporary Guidelines in Whole-Breast Irradiation: an Alternative Perspective.

Recht A(1), McArthur H(2), Solin LJ(3), Tendulkar R(4), Whitley A(5), Giuliano
A(6).

The American Society for Radiation Oncology (ASTRO) produced an evidence-based
guideline on whole-breast radiation therapy for patients with early-stage
invasive breast cancer and ductal carcinoma in situ. This commentary points out
areas where we believe the data are too limited to make definitive
recommendations and where alternative approaches are also supported by evidence.

Copyright © 2018 Elsevier Inc. All rights reserved.

DOI: 10.1016/j.ijrobp.2018.10.014
PMID: 30366007

_____________________________________________________________________________________

1. Breast Cancer Res Treat. 2017 Sep;165(2):445-453. doi: 10.1007/s10549-017-4345-y.
Epub 2017 Jun 21.

Utilization of hypofractionated whole-breast radiation therapy in patients
receiving chemotherapy: a National Cancer Database analysis.

Diwanji TP(1), Molitoris JK(1), Chhabra AM(1), Snider JW(1), Bentzen SM(2),
Tkaczuk KH(3), Rosenblatt PY(3), Kesmodel SB(4), Bellavance EC(4), Cohen RJ(5),
Cheston SB(5), Nichols EM(5), Feigenberg SJ(6).



PURPOSE: Results from four major hypofractionated whole-breast radiotherapy
(HF-WBRT) trials have demonstrated equivalence in select patients with
early-stage breast cancer when compared with conventionally fractionated WBRT
(CF-WBRT). Because relatively little data were available on patients receiving
neoadjuvant or adjuvant chemotherapy, consensus guidelines published in 2011 did
not endorse the use of HF-WBRT in this population. Our goal is to evaluate trends
in utilization of HF-WBRT in patients receiving chemotherapy.
METHODS AND MATERIALS: We retrospectively analyzed data from 2004 to 2013 in the
National Cancer DataBase on breast cancer patients treated with HF-WBRT who met
the clinical criteria proposed by consensus guidelines (i.e., age >0 years,
T1-2N0, and breast-conserving surgery), regardless of receipt of chemotherapy. We
employed logistic regression to delineate and compare clinical and demographic
factors associated with utilization of HF-WBRT and CF-WBRT.
RESULTS: A total of 56,836 women were treated with chemotherapy and WBRT (without
regional nodal irradiation) from 2004 to 2013; 9.0% (n = 5093) were treated with
HF-WBRT. Utilization of HF-WBRT increased from 4.6% in 2004 to 18.2% in 2013
(odds ratio [OR] 1.21/year; P < 0.001). Among patients receiving chemotherapy,
factors most dramatically associated with increased odds of receiving HF-WBRT on
multivariate analysis were academic facilities (OR 2.07; P < 0.001), age >80 (OR
2.58; P < 0.001), west region (OR 1.91; P < 0.001), and distance >50 miles from
cancer reporting facility (OR 1.43; P < 0.001). Factors associated with decreased
odds of receiving HF-WBRT included white race, income <$48,000, lack of private
insurance, T2 versus T1, and higher grade (all P < 0.02).
CONCLUSIONS: Despite the absence of consensus guideline recommendations, the use
of HF-WBRT in patients receiving chemotherapy has increased fourfold
(absolute = 13.6%) over the last decade. Increased utilization of HF-WBRT should
result in institutional reports verifying its safety and efficacy.

DOI: 10.1007/s10549-017-4345-y
PMID: 28639030 [Indexed for MEDLINE]

 

[SneakyBooger]

From Red Journal, 2012, Hau et al:
4500 +1600 boost superior to 5000 (w/o boost)

 

[SneakyBooger]

From Red Journal, 2012, Hau et al:
4500 +1600 boost superior to 5000 (w/o boost)

Wonder how much worse cosmesis would have been with 5000 + Boost.

 

[SneakyBooger]

Wonder how much worse cosmesis would have been with 5000 + Boost.

If 5000 worse than 4500+boost, why trials choose 5000? Why not choose the superior standard treatment to compare?

 

[Burt Radnolds]

Sounds high risk in a young woman.

4500 at 180 f/b boost to lump site(s) of 1620 at 180.

Why would you choose a whole breast dose on the low end of the appropriate range in this case when the high risk region is not clearly defined?

 

[SneakyBooger]

Why would you choose a whole breast dose on the low end of the appropriate range in this case when the high risk region is not clearly defined?

Boost in oncoplastic pts not well studied. I usually treat the quadrant involved unless my plastic surgeon tells me otherwise. BTW, total breast dose always higher once the 3DCRT boost is plan summed.

Certainly appreciate hearing your thoughts on higher doses though.

 

[SneakyBooger]

Hypofractionation has a checkered past in breast cancer, think about brachial plexopathy. Brach plex takes 15+ years before becoming evident in a population with latency up to 30 years. Especially impt in younger age group.

 

[xrthopeful]

can't wait until the old guard of rad onc who don't believe in hypofrac are phased out.

retire already.

 

[SneakyBooger]

Not sure what it was I said, but he/she doesn't sound "hopeful" actually.

BTW, I believe. I do it. But I surely don't do it blindly.

 

[SneakyBooger]

can't wait until the old guard of rad onc who don't believe in hypofrac are phased out.

retire already.

If you have the data disproving any of what was posted, don't hide it. We all very much need to see and evaluate it.

I understand that in the Era and Hype of Guidelines there are those who prefer others to tell them what to do rather than think for themselves.

Still, better this "old guard" show this here rather than when it comes as part of a Notice Of Intent for the younger rad oncs. And the NOI will come.

You are a smart person. I admire you. Anyone can make smartass comments. I encourage you to do better. Patients deserve it. The next generation of residents deserve it.

#NotKeepingMyHeadInTheSand

 

[theradiator]

Right on! In God we trust, all others bring data. Not expert opinion = level 7 evidence.

 

[SneakyBooger]

Right on! In God we trust, all others bring data. Not expert opinion = level 7 evidence.[/QUOTE

Just as I was getting ready to go watch some NCAA bball, this arrived in my email.

 

[Burt Radnolds]

Just as I was getting ready to go watch some NCAA bball, this arrived in my email.

Saw this come across on Doximity as well. Very interesting article but pretty sure it has nothing to do with hypofractionation. It's funny that you named your files SWEDISH_HYPOFRAC when the vast majority of patients included were treated at 2 Gy per fraction. Also, that p value you circled in red regarding fractionation has nothing to do with heart disease risk, and even if it did only 12% (22 patients) were treated with hypofractionation, hardly enough to draw any conclusions from. Lastly, I typically don't pass any radiation beam through the heart or LAD when I treat whole breast, so even if hypofractionation somehow did elevate your risk of LAD CAD, it still wouldn't matter.

 

[medgator]

Right on! In God we trust, all others bring data. Not expert opinion = level 7 evidence.

Isn't that essentially what the updated ASTRO guideline on hypo-fx in breast was in trying to expand its use to pretty much every node-negative post-lumpectomy pt out there? I will be the first to agree that the data looks solid in the groups that the data exists for, and I probably hypo-fx >80% of my pts at this point.

But I'm sorry but if you're a youngish pt with a triple-negative breast CA, you're getting 60.4/33 in my practice. A recent randomized study in the JCO suggests there may be some interplay with chemo and hypo-fx, and not in a good way.

 

[SneakyBooger]

p-value with a rectangle, but I know what you meant.

Also, the study is examining incidental dose to the heart. None of us (hopefully) pass dose directly thru the heart unless absolutely necessary. So, your plans are applicable. So are mine. And every rad onc's. We all have incidental cardiac exposure, including protons.

Not sure the effect has nothing to do with hypofractionation, as the only variable in the table with a significant p-value is fractionation. However, I saw no discussion in the paper of what the meaning of that p-value was. Did you find an explanation of it? Let me know if you do. Because one of the concerns of hypofractionation is that we don't have the elusive long term toxicity data.

I also note that despite Sweden's healthcare being essentially a socialist program that hypofractionation wasn't the predominant regimen reported. Why not? However, they are a very fortunate rich country and can afford to provide whatever regimen they deem appropriate.

Or do they know something we are ignoring.

But, as I was rushing in to watch the games I thought I would post it and see what the peanut gallery would say. Glad to see that someone is examining my posts and I appreciate your discourse.

I still wonder what it is they are trying to tell us...

 

[Burt Radnolds]

p-value with a rectangle, but I know what you meant.

Also, the study is examining incidental dose to the heart. None of us (hopefully) pass dose directly thru the heart unless absolutely necessary. So, your plans are applicable. So are mine. And every rad onc's. We all have incidental cardiac exposure, including protons.

Not sure the effect has nothing to do with hypofractionation, as the only variable in the table with a significant p-value is fractionation. However, I saw no discussion in the paper of what the meaning of that p-value was. Did you find an explanation of it? Let me know if you do. Because one of the concerns of hypofractionation is that we don't have the elusive long term toxicity data.

I also note that despite Sweden's healthcare being essentially a socialist program that hypofractionation wasn't the predominant regimen reported. Why not? However, they are a very fortunate rich country and can afford to provide whatever regimen they deem appropriate.

Or do they know something we are ignoring.

But, as I was rushing in to watch the games I thought I would post it and see what the peanut gallery would say. Glad to see that someone is examining my posts and I appreciate your discourse.

I still wonder what it is they are trying to tell us...

1) You got me, I said circled but you rectangled the number.

2) I disagree that the study is about incidental dose to LAD. The only statistically significant finding was for a mean mid LAD dose above 20Gy, which is most commonly seen with direct overlap or literally having the block edge abutting the LAD.

3) Agree that those p values are not well explained but they are in the methods/ patient characteristics section where it would be inappropriately/unlikely to bury results.

4) I think if they were wanting to tell us something, they would tell us.

5) I don't see that excerpt you attached to your post anywhere in the actual article we are discussing, where is it from? You are really are a sneaky booger... 😉

 

[SneakyBooger]

4) I think if they were wanting to tell us something, they would tell us.

5) I don't see that excerpt you attached to your post anywhere in the actual article we are discussing, where is it from? You are really are a sneaky booger... 😉

4) Agreed. Who is listening?

5) Sorry. Should have included reference (RedJ, 2013)

 

[SneakyBooger]

What is everyone's thoughts about the EORTC randomized data with positive margin and boost dose?

Someone mentioned a French study. Would anybody be able to provide the reference? (Thanks in advance)