Suggested guidelines for appropriate patient selection for
patients undergoing Accelerated Partial Breast Irradiation at
DMC.
Tonya Echols Cole, MD
Patient Evaluation
• Multidisciplinary; before surgery
– Breast Surgeon
– Radiation Oncologist
– Medical Oncologists
Types of APBI
• Interstitial
• Intraoperative
– Electron
– 50 Kv
• Balloon cavitary
– Mammosite
– Contura
– Savi
• External Beam
– 3D conformal
– IMRT
Current Guidelines- Old
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•
•
•
•
ASBS - 2005
ABS - 2007
European Collaborative Group - 2009
ACRO - 2008
ASTRO- 2009
Additional Studies
• At least 5 randomized trials
– Short follow-up
– Outdated or nonstandard technique
– Lack of power
• At least 41 non randomized trials
– Many with at least 10 year follow-up
Clinical Trial Results
• ASBS Mammosite Registry Trial
– 44 month follow-up on first 400 cases.
– Cancer specific survival of 100%
– Local recurrence rate between 0-2.65%
• DCIS Phase II Clinical Study
– 15 month follow-up on 100 patients
– 3% local recurrence rate
ACCELERATED PARTIAL BREAST RADIATION RECURRENCE RATE STUDY
(QI 2013 4-6)
TONYA ECHOLS COLE, MD & TERRI RICHARDSON, RHIA,CTR
Retrospective review of 330 analytic cases of breast cancer
treated with accelerated partial breast irradiation from 2006
to present
• 330 APBI procedure
• 72% (239) were invasive
• 28% (91) were DCIS
Recurrences
•
•
•
•
•
14 total recurrences ( 4.2%)
7 Local (2.1%)
3 Regional (0.9%)
4 Distant (1.2%)
Median time to recurrence was 53 months
Local Recurrences
7 local recurrences
2.1% recurrence rate
All patients were >50 yrs. old
All tumors <3cm
 3 were DCIS or 3/91 or 3.3%
 2 of the 3 did not take Tamoxifen (pt. refusal or medically
contraindicated.)
 All were ER+
 4 were invasive 4/239 or 1.7%
 1 was triple negative 2 were triple +
Regional Recurrences
• 3 regional recurrences 3/330 ( 0.9%)
– All invasive cancer <3cm
– All >60 yrs. old
– 2 were triple -, 1ER+, Her2+
– All had 3 lymph nodes examined
Distant recurrences
• 4 Distant recurrences 4/330 (1.2%)
• 75% ¾ were invasive
– All >50 yrs. old
– All tumors <3cm
– All were ER+
• All received hormonal therapy
• 1 received chemotherapy
• 25% (1/4) DCIS
– Was ER -
Conclusions
• Local recurrence rates for patients treated
with accelerated partial breast radiation
therapy at DMC are comparable to published
data.
• There was no group or subset found to be at
increased risk of recurrence.
Acceptable
•
•
•
•
•
•
•
Age > 50
Size < 3 cm
Histology
ER
Margins
LVI
Nodal status
All invasive subtypes and DCIS
Positive or negative
Negative
Not present
negative
Not acceptable
Outside of a clinical Trial
• Node positive
• Tumors > 3cm including
DCIS
• Extensive LVSI
• Neoadjuvant chemo
• Age <45
• Multicentric
• Microscopically multifocal
>3cm
• EIC > 3cm
• Margins +
• Nodal surgery- not
performed.
• BRCA +
Future Directions
• Recommendations should be updated
annually as new results from prospective
randomized trials are released.