| |
INDICATIONS
AND CONSIDERATIONS |
TECHNIQUE |
| NON-INVASIVE
DISEASE GUIDELINES |
| DCIS |
After
breast conserving surgery, margins clear
Margins
< 3mm wider excision recommended prior to adjuvant RT |
Two-field
tangential beams
- 4250 cGy in 16 fractions or 5000 cGy
in 25 fractions
- or partial breast
treatment (one week) as per OCOG study
- Margins of > 3mm are recommended
(deep margin is an exception if went to fascia)
-
Boost can be applied if patient declines re-excision.
|
| INVASIVE
DISEASE GUIDELINES |
| SEGMENTAL
RESECTION
Lymph Node
Negative |
All patients recommended
radiotherapy following segmental resection |
Tangential
breast fields
- 4250 cGy in 16 fractions
- 5000 cGy in 25
fractions
- 4500 cGy in 20
fractions
Or partial breast
treatment (one week) as per OCOG study (for tumors <3 cm) |
| SEGMENTAL RESECTION Lymph
Node Positive |
1-3
positive nodes |
For
both pre- and post-menopausal patients, regional nodal radiation
is not recommended. Results from MA-20 will clarify whether
nodal radiation is of benefit in this group. |
| |
Any number of
nodes resected with 4 or more positive; pre- or post-menopausal |
-
Radiation to breast and regional nodes, including IMC's:
- 5000 cGy
in 25 fractions
- 4500 cGy
in 20 fractions
- If > 10 nodes
resected, may exclude axilla and treat IMC/supraclavicular
area only |
| |
|
|
| MASTECTOMY |
-
tumor > 5 cm
- skin involvement
- muscle
involvement
|
Radiation
to chest wall and regional lymph nodes, including the IMC's
- 5000 cGy in 25
fractions
- 4500 cGy in 20
fractions
|
| |
-
1 - 3 nodes positive |
All
patients to be referred for radiation oncologist consultation:
Pre-menopausal-regional
nodal radiation in this setting is individualized.
Post-menopausal
- If tamoxifen only used, regional nodal radiaiton, including
IMC's is recommended. When chemotherapy is used, regional
nodal radiaiton in this setting is individualized.
- 4500 cGy in 20
fractions
- 5000 cGy in 25
fractions
Addendum: The data
from the Danish update for pre-menopausal, 1-3+ nodes shows
a survival benefit when CMF chemotherapy was given. There
is no survival data from the Danish study in post-menopausal,
1-3+ nodes treated with chemotherapy as they were all treated
with Tamoxifen. The absolute benefit of locoregional radiotherpy,
in reduction of locoregional recurrence, is in the range of
5%. |
| |
Any munber of nodes resected
with 4 or more positive; pre-or post-menopausal |
Chest
wall and regional nodal radiotherapy, including IMC's:
- 5000 cGy in 25
fractions
- 4500 cGy in 20
fractions
If >10 nodes
resected, may exclude axilla and treat IMC/supraclavicular
area only |
| MARGINS
NOT CLEAR - INVASIVE AND NON-INVASIVE DISEASE |
Breast
conserving surgery:
RADIATION
BOOST |
Primary
recommendation:
further surgery to clear margins
|
If
wider excision not an option
- 1000 cGy in 4
or 5 fractions if whole breast treated to 4250 cGy in 16 fractions
- Recommend 1000
cGys in 5 fractions or 1600 cGys in 8 fractions when 5000
cGy in 25 fractions used or 4500 cGy in 25 fractions (as an
option in large breasted patients)
-Boost recommended
to be sequential to tangent treatments
-All women under
age 40 recommended to have boost even if clear margins
-Over age 40 boost
for <3 mm margins at the discretion of RO
For post-mastectomy
patients, no radiation recommended if margins close or focally
positive. If grossly positive resection margin, there may
be benefit from chest wall radiation.
(Tamoxifen should
also be considered (ER status may help decide which patient
benefits) if patient had DCIS only). Bolus is recommended
if radiation is delivered to chest wall. Details of bolus
are at radiation oncologist's discretion.
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