Livi breast experience

[madchemist89]

I'm planning to start doing livi breast regimen for some of my patients. Does anyone have any real world advice or tips regarding this treatment regimen?

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[jondunn]

Welcome to the rest of your life. You won’t look back

 

[RADONC4285]

I'm planning to start doing livi breast regimen for some of my patients. Does anyone have any real world advice or tips regarding this treatment regimen

I'm planning to start doing livi breast regimen for some of my patients. Does anyone have any real world advice or tips regarding this treatment regimen?

It works great for the right patient. I still mostly do it for those who meet ASTRO PBI guidelines. You do need clips and a relatively well defined cavity. I've had pts switched to whole breast becauee the cavity was massive or ill defined. In terms of tox, it's phenomenal. Hardly anything acute

 

[madchemist89]

How do you set up your fields? Partial arcs?

 

[Krukenberg]

Welcome to the rest of your life. You won’t look back

How is it you’re doing PBI so much that it comprises that much of your practice? I’d say about 10%of the patients I see are suitable candidates for PBI

 

[medgator]

How is it you’re doing PBI so much that it comprises that much of your practice? I’d say about 10%of the patients I see are suitable candidates for PBI

He also never pegs a h&n pt under any circumstance.... eek.

Only a sith deals in absolutes!

 

[evilbooyaa]

I'd estimate only about 33% or so of my tangent breast patients are purely suitable for APBI. Some have close margins, some got chemo at some point, some are T2, some have a few of these factors.

For OP - I frequently relax my contralateral breast point dose < 1Gy, especially for medial tumors. Most of these patients are > 50-60 years old and I just don't think it makes that big of a deal to have a point dose of like 2-5Gy to the contralateral breast.

Partial arcs probably most common. To me mini tangents can treat a very large portion of the breast dependent on location of the seroma.

Sometimes not feasible due to large seroma in a small breast.

I don't always need clips if there is a sizable seroma. Sometimes on IGRT, making sure the skin contour is similar enough for your PTV_Eval requires some close evaluation. I always try to see these patients after treatment 1 or 2 to make sure they're using skin creams because otherwise you'll see them too late for it to have done anything (if skin creams are even necessary, but not ready to make that leap yet).

 

[jondunn]

How is it you’re doing PBI so much that it comprises that much of your practice? I’d say about 10%of the patients I see are suitable candidates for PBI

I mean if you see a lot of breast, you'll see a lot of partial breast.

 

[OTN]

I'd love to be able to do Livi, but 95% of my breast patients get oncoplastic lumpectomies.

 

[BobbyHeenan]

I'm a HUGE Livi fan.

Of course I haven't been doing it long enough to see any failures, but from a cosmesis/tolerance standpoint it's unreal. I've had a high volume breast practice for a while and dabbled in SAVI/Mammosite as well.

As long as you can see a cavity and no crazy oncoplastic reconstruction, Livi is the way to go.

I typically treat only ASTRO suitable cases but I'm flexible on the "cautionary cases" with appropriate discussion. Breast surgeon guidelines are alittle more lenient if you so desire.

https://www.breastsurgeons.org/docs/statements/Consensus-Statement-for-Accelerated-Partial-Breast-Irradiation.pdf

 

[Palex80]

I'd love to be able to do Livi, but 95% of my breast patients get oncoplastic lumpectomies.

We have used Livi in patients post oncoplastic lumpectomies too.
You need to speak with your breast surgeon, understand what he is doing, describe to him where you want the clips and it can still be done for the majority of patients post oncoplastic lumpectomy. That is my experience, at least.

 

[RickyScott]

Welcome to the rest of your life. You won’t look back

A lot of our patients qualify, but still need to keep the lights on. Don’t think one vs 3 weeks makes a convenience difference. Can still do partial breast over 3 weeks. “Won’t look back” - 5 treatments for most breast and prostate is the end of our specialty.

 

[jondunn]

A lot of our patients qualify, but still need to keep the lights on. Don’t think one vs 3 weeks makes a convenience difference. Can still do partial breast over 3 weeks. “Won’t look back” - 5 treatments for most breast and prostate is the end of our specialty.

Import low fantastic too. Treating less breast is just great, no matter how you do it

We ran the numbers and for us livi reimburses about 70 percent as 15 fraction 3D

 

[RickyScott]

Import low fantastic too. Treating less breast is just great, no matter how you do it

We ran the numbers and for us livi reimburses about 70 percent as 15 fraction 3D

I am not privy to our non Medicare billing, but I do know it is a fraction of the regional nci pps exempt center. If most our prostates/breasts go to 5 fraction, and 8 gy x 1 mets, we would not be financially viable. I am sure hospital wouldn’t close program down, but will be very painful.

 

[metallica81788]

I've been using it for pretty much any patient that would meet observation criteria (65+ and suitable) for almost two years now and it's fantastic. I've only had a few patients pick observation, so you will gain some patients that may not have got on beam for 3 weeks.
I will bend the criteria a little bit depending on individual situations but tell my patients I always have the right to switch back to whole breast after simulation.

 

[BobbyHeenan]

I've been using it for pretty much any patient that would meet observation criteria (65+ and suitable) for almost two years now and it's fantastic. I've only had a few patients pick observation, so you will gain some patients that may not have got on beam for 3 weeks.
I will bend the criteria a little bit depending on individual situations but tell my patients I always have the right to switch back to whole breast after simulation.

YES!

5 treatments is nice “insurance” to have in the bank when you’re miserable in year two of the AI and want to be done with it.

 

[metallica81788]

5 treatments is nice “insurance” to have in the bank when you’re miserable in year two of the AI and want to be done with it.

That's pretty much exactly what I tell them - no matter what happens with endocrine therapy down the road, you've already locked in some benefit with radiation. 98% of the time it works every time.

 

[Ray D. Ayshun]

For those of you doing this, breath hold 100% of the time? It doesn't look like that was the protocol.

 

[BobbyHeenan]

For those of you doing this, breath hold 100% of the time? It doesn't look like that was the protocol.

I do it at sim for L side, but often don't use it. Just depends on anatomy, location, and obviously ability for patient to breath hold.

The breath hold CBCT "spotlight" scan on the truebeam is a really nice option though. Or even just breath hold align to clips if you can see them well.

 

[elementaryschooleconomics]

I do it at sim for L side, but often don't use it. Just depends on anatomy, location, and obviously ability for patient to breath hold.

The breath hold CBCT "spotlight" scan on the truebeam is a really nice option though. Or even just breath hold align to clips if you can see them well.

Same. Love the TrueBeam spotlight feature.

 

[seper]

CBCT on breast is no ideal, since you have to shift the table

 

[evilbooyaa]

For those of you doing this, breath hold 100% of the time? It doesn't look like that was the protocol.

Breath hold in L breast (to me) matters when you're running a tangent beam and trying to actively separate from the heart. I feel comfortable enough aggressively sparing the heart with VMAT planning without BH. Sometimes static field IMRT to pick beam angles that have zero exit into the heart if tumor happens to be very close (medial/inferior quadrant).

But, I think if you have BH and feel good about BH CBCT then I'd be OK with it.

 

[RickyScott]

Breath hold in L breast (to me) matters when you're running a tangent beam and trying to actively separate from the heart. I feel comfortable enough aggressively sparing the heart with VMAT planning without BH. Sometimes static field IMRT to pick beam angles that have zero exit into the heart if tumor happens to be very close (medial/inferior quadrant).

But, I think if you have BH and feel good about BH CBCT then I'd be OK with it.

Agreed. Extremely rare for partial breast with imrt that would need breath hold for separation. Can’t ever remember a case.

 

[Ray D. Ayshun]

Right, but we're talking about doing VMAT, not tangents, on a target that moves while neither doing motion evaluation nor management. Seems like we're making "pretty" apbi plans, which is fine as this is the patient population onto whose nipple you could pipette a microliter of technetium and get the same LRFS.

 

[RickyScott]

Right, but we're talking about doing VMAT, not tangents, on a target that moves while neither doing motion evaluation or management. Seems like we're making "pretty" apbi plans.

I think the chest wall is relatively stable w typical respiration (around 3 mm when not using accessory muscles). Don’t see much with vision rt.

 

[evilbooyaa]

Right, but we're talking about doing VMAT, not tangents, on a target that moves while neither doing motion evaluation nor management. Seems like we're making "pretty" apbi plans, which is fine as this is the patient population onto whose nipple you could pipette a microliter of technetium and get the same LRFS.

I mean... there's still a PTV margin. Original Livi trial did 1cm. I'm comfortable with 5mm if doing daily CBCT. If you're anxious you can do 1cm, that should remove most concerns as you're doing it exactly as the trial did, resulting in equivalent outcomes.

Are you suggesting that we do a 4DCT for this breast cancer treatment?

 

[Ray D. Ayshun]

I mean... there's still a PTV margin. Original Livi trial did 1cm. I'm comfortable with 5mm if doing daily CBCT. If you're anxious you can do 1cm, that should remove most concerns as you're doing it exactly as the trial did, resulting in equivalent outcomes.

Are you suggesting that we do a 4DCT for this breast cancer treatment?

Just playing devil's advocate a little given our approach to other sites in the thorax. To answer the question, in principle, yes. Though I might feel more comfortable just doing breath hold on everyone seeing as it's a target and surface-air interface that are moving throughout treatment. I imagine the PTV is the PTV_eval, or some variation thereof.

 

[ramsesthenice]

What’s going on here? Everyone seems like they are having a happy discussion about breast cancer management with minimal discourse. Oh god, am I having a nervous break or something? I can’t be seeing this right.

 

[thecarbonionangle]

What’s going on here? Everyone seems like they are having a happy discussion about breast cancer management with minimal discourse. Oh god, am I having a nervous break or something? I can’t be seeing this right.

Just say you into RNI and the thread will spiral out of control. This is a very fine balance

 

[deleted1111261]

Breath hold in L breast (to me) matters when you're running a tangent beam and trying to actively separate from the heart. I feel comfortable enough aggressively sparing the heart with VMAT planning without BH. Sometimes static field IMRT to pick beam angles that have zero exit into the heart if tumor happens to be very close (medial/inferior quadrant).

But, I think if you have BH and feel good about BH CBCT then I'd be OK with it.

That’s not why I’ve been doing it for VMAT with Livi. The rationale is to hold the breast still. Open fields for a tangent plan “blur” over the course of multiple fractions, but in this case want to be exact and can have that lower PTV margin. That being said, Livi has amazing local control and toxicity outcomes. I just think Chirag Shah’s (and by extension) outcomes will be marginally better 😊

 

[Ray D. Ayshun]

That’s not why I’ve been doing it for VMAT with Livi. The rationale is to hold the breast still. Open fields for a tangent plan “blur” over the course of multiple fractions, but in this case want to be exact and can have that lower PTV margin. That being said, Livi has amazing local control and toxicity outcomes. I just think Chirag Shah’s (and by extension) outcomes will be marginally better 😊

So coming back to this, you do breath hold in right breast with Livi regimen using VMAT?

 

[deleted1111261]

So coming back to this, you do breath hold in right breast with Livi regimen using VMAT?

I do. Maybe it doesn’t sense but I like how it works and we do surface guidance as well. Feel very comfortable with small margin.

 

[elementaryschooleconomics]

I do. Maybe it doesn’t sense but I like how it works and we do surface guidance as well. Feel very comfortable with small margin.

I do as well, with the justification in this context being reducing my chance of a geographic miss.

 

[grenz]

I’ll be curious to see how feelings change about Livi when you have your first LR and get blamed for doing PBI.

Have definitely heard surgeons say “in retrospect I wish she had gotten radiation” for LRs after omission.

 

[BobbyHeenan]

I’ll be curious to see how feelings change about Livi when you have your first LR and get blamed for doing PBI.

Have definitely heard surgeons say “in retrospect I wish she had gotten radiation” for LRs after omission.

I wonder about this too but so far so good (fingers crossed).

The difference in cosmesis/tolerance between whole breast hyopfrac and 30/5 APBI QOD is DRASTIC, especially for larger cup size ladies. I've fallen in love with this regimen.

 

[deleted1111261]

I’ll be curious to see how feelings change about Livi when you have your first LR and get blamed for doing PBI.

Have definitely heard surgeons say “in retrospect I wish she had gotten radiation” for LRs after omission.

It’s possible, but the studies show a minimal difference. If it did happen … salvage lumpectomy and then .. BID?

 

[HolySmokes]

I’ll be curious to see how feelings change about Livi when you have your first LR and get blamed for doing PBI.

Have definitely heard surgeons say “in retrospect I wish she had gotten radiation” for LRs after omission.

I don't know what others experience is like, but my breast team has completely bought in to PBI and they think 30/5 is the best thing since sliced bread.

 

[Mandelin Rain]

I don't know what others experience is like, but my breast team has completely bought in to PBI and they think 30/5 is the best thing since sliced bread.

Many studies shown unsliced bread is cheaper, more efficient, and non-inferior tastewise. SMH at the greed.

 

[Ray D. Ayshun]

So who's doing QD vs QOD then?

 

[deleted1111261]

So who's doing QD vs QOD then?

Icro and chirag do QD. So that’s what I do

 

[Mandelin Rain]

I make them bring in a friend with breast cancer so I can treat them both QOD in the same time slot over 10 days.

It's a new QI project we call Breast Buddies.

Everyone hates it.

 

[OTN]

QOD

 

[TheWallnerus]

I make them bring in a friend with breast cancer so I can treat them both QOD in the same time slot over 10 days.

It's a new QI project we call Breast Buddies.

Everyone hates it.

 

[HolySmokes]

I offer both. Patients who live close often take the QD while patients driving in from out of town will opt for QOD if they don't/can't stay in town for a week. Anecdotally, I have seen no difference in toxicity

 

[Burt Radnolds]

I'm sure I'll get maligned by the breast nihilists but I exclusively use QOD when giving 30 Gy. It probably doesn't matter but we are dealing with a single center study who did things a very specific way and I would like to replicate those favorable results to the best of my ability. We have proven in FAST and FAST-FORWARD that we are the knife's edge of small but meaningful toxicity difference in the 26-30Gy range given over 5 fractions in breast cancer. While the vast majority of meaningful sublethal repair has likely occurred by the next day, there are some signals in the SBRT literature (depending on what you want to believe) regarding QOD being more favorable than QD.

However, if you want to dial your dose down to 26Gy per FAST and extrapolate that to partial breast per IMPORT-LOW as they do in the UK, then QD becomes more evidence supported.

 

[TheWallnerus]

I'm sure I'll get maligned by the breast nihilists but I exclusively use QOD when giving 30 Gy. It probably doesn't matter but we are dealing with a single center study who did things a very specific way and I would like to replicate those favorable results to the best of my ability. We have proven in FAST and FAST-FORWARD that we are the knife's edge of small but meaningful toxicity difference in the 26-30Gy range given over 5 fractions in breast cancer. While the vast majority of meaningful sublethal repair has likely occurred by the next day, there are some signals in the SBRT literature (depending on what you want to believe) regarding QOD being more favorable than QD.

However, if you want to dial your dose down to 26Gy per FAST and extrapolate that to partial breast per IMPORT-LOW as they do in the UK, then QD becomes more evidence supported.

And that’s why I never use the Livi dose

Who knows thanks to you!

But the UK RCR explained it very well too

30 Gy is “overkill”

 

[deleted1111261]

I'm sure I'll get maligned by the breast nihilists but I exclusively use QOD when giving 30 Gy. It probably doesn't matter but we are dealing with a single center study who did things a very specific way and I would like to replicate those favorable results to the best of my ability. We have proven in FAST and FAST-FORWARD that we are the knife's edge of small but meaningful toxicity difference in the 26-30Gy range given over 5 fractions in breast cancer. While the vast majority of meaningful sublethal repair has likely occurred by the next day, there are some signals in the SBRT literature (depending on what you want to believe) regarding QOD being more favorable than QD.

However, if you want to dial your dose down to 26Gy per FAST and extrapolate that to partial breast per IMPORT-LOW as they do in the UK, then QD becomes more evidence supported.

That’s all correct and if you’re a purist, that makes sense and do it that way. I think it’s probably the safest way to do it. I think NCCN says QOD and some people think of NCCN as their security blanket (in a good way - legal protection).

I believe the Florence people have treated more patients “off protocol” with QD then on protocol with QOD… so, if you want to say do it like them, they do it QD. Marketing-wise - and yes that is a cynical reason to do anything - one week sounds better than two.

I don’t believe 27 and 26 Gy are as different as the studies say. That makes very little sense to me. But, maybe it’s true?

And 26 is enough for whole breast, so it should be enough for partial. But, 30 to a smaller volume gives me an automatic boost with very little difference in toxicity. 2.5cm gets 26, 1.5cm gets 30.

This is my logic.

 

[evilbooyaa]

That’s not why I’ve been doing it for VMAT with Livi. The rationale is to hold the breast still. Open fields for a tangent plan “blur” over the course of multiple fractions, but in this case want to be exact and can have that lower PTV margin. That being said, Livi has amazing local control and toxicity outcomes. I just think Chirag Shah’s (and by extension) outcomes will be marginally better 😊

People did lung SBRT before 4D was a thing with margins of similar size. However, most wouldn't now, so I understand rationale for it in a motivated patient capable of BH. However, whether it is clinically meaningful in terms of dosimetry improvements (for which we justify use of DIBH in L-sided breast in terms of heart dose, and some are doing now in R-sided breast + RNI due to lung dosimetry) I think is an interesting question.

4DCT for breast APBI next frontier for those who can't do DIBH?

 

[deleted1111261]

People did lung SBRT before 4D was a thing with margins of similar size. However, most wouldn't now, so I understand rationale for it in a motivated patient capable of BH. However, whether it is clinically meaningful in terms of dosimetry improvements (for which we justify use of DIBH in L-sided breast in terms of heart dose, and some are doing now in R-sided breast + RNI due to lung dosimetry) I think is an interesting question.

4DCT for breast APBI next frontier for those who can't do DIBH?

Yah I think that sounds reasonable ?

 

[evilbooyaa]

So who's doing QD vs QOD then?

QOD camp here

I'm sure I'll get maligned by the breast nihilists but I exclusively use QOD when giving 30 Gy. It probably doesn't matter but we are dealing with a single center study who did things a very specific way and I would like to replicate those favorable results to the best of my ability. We have proven in FAST and FAST-FORWARD that we are the knife's edge of small but meaningful toxicity difference in the 26-30Gy range given over 5 fractions in breast cancer. While the vast majority of meaningful sublethal repair has likely occurred by the next day, there are some signals in the SBRT literature (depending on what you want to believe) regarding QOD being more favorable than QD.

However, if you want to dial your dose down to 26Gy per FAST and extrapolate that to partial breast per IMPORT-LOW as they do in the UK, then QD becomes more evidence supported.

Agree. If doing something 'out of the norm' (norm in the US in this scenario defined as 40/15 +/- boost in 2022), I, as someone who is dedicatedly NOT a breast expert and have not been offering APBI for 5+ years, would personally stick with, as a preference, something supported by a published protocol. Do something 'as per protocol'.

Now, I wonder how much of Chirag (although likely less so than many other US Academic Rad Oncs as they attempt to shorten schedules to facilitate patients travelling to their center for financially toxic treatments) likes qD because his consults go more "well come stay for a week in Cleveland, get the magic CCF beam, it's only a week! and your toxicities will be less than getting that dirty whole breast treatment back home" as opposed to "yeah you'll have to come back the second week or stay through the weekend"

No one has done 30/5 for 5-10 years except the Florence group, so deviating from that protocol is likely fine, but I like to KISS.