Radiation therapy techniques for newly diagnosed, non-metastatic breast cancer
- Lori J Pierce, MD
Lori J Pierce, MD
- Section Editor — Radiation Therapy
- Professor of Radiation Oncology
- University of Michigan School of Medicine
Radiation therapy (RT) is a critical component of therapy for women with newly diagnosed, non-metastatic breast cancer. RT techniques for women with newly diagnosed, non-metastatic invasive breast cancer will be reviewed here. An overview of RT techniques in cancer treatment is discussed separately. (See "Radiation therapy techniques in cancer treatment".)
The approach to adjuvant RT for women with newly diagnosed, non-metastatic breast cancer and the long-term complications of breast RT are covered separately. (See "Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer" and "Patterns of relapse and long-term complications of therapy in breast cancer survivors".)
CHOICE OF PARTICLES FOR RADIATION THERAPY
Therapeutic radiation consists of the delivery of radiation beams comprised of electrons or photons. Photons completely pass through tissues, so when used, they must be angled to traverse the target tissue only so as to avoid critical normal tissue (eg, the heart). In contrast, electrons traverse only to a specific depth (determined by the energy needed) and hence can be tailored to target the tissue of interest while sparing critical tissue. Therefore, they can be delivered directly over critical tissues. (See "Radiation therapy techniques in cancer treatment", section on 'Photons versus electrons'.)
Three anatomic regions must be considered in defining the target volume (figure 1) (see "Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer"):
●The breast or chest wall (depending on the surgical approach used), which constitute the primary radiation therapy (RT) field (See 'Primary field' below.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Fletcher GH, Montague ED. Does adequate irradiation of the internal mammary chain and supraclavicular nodes improve survival rates? Int J Radiat Oncol Biol Phys 1978; 4:481.
- Marks LB, Hebert ME, Bentel G, et al. To treat or not to treat the internal mammary nodes: a possible compromise. Int J Radiat Oncol Biol Phys 1994; 29:903.
- Baker GR. Localization: conventional and CT simulation. Br J Radiol 2006; 79 Spec No 1:S36.
- Madu CN, Quint DJ, Normolle DP, et al. Definition of the supraclavicular and infraclavicular nodes: implications for three-dimensional CT-based conformal radiation therapy. Radiology 2001; 221:333.
- Bentel GC, Marks LB. A simple device to position large/flaccid breasts during tangential breast irradiation. Int J Radiat Oncol Biol Phys 1994; 29:879.
- Bornstein BA, Cheng CW, Rhodes LM, et al. Can simulation measurements be used to predict the irradiated lung volume in the tangential fields in patients treated for breast cancer? Int J Radiat Oncol Biol Phys 1990; 18:181.
- Neal AJ, Yarnold JR. Estimating the volume of lung irradiated during tangential breast irradiation using the central lung distance. Br J Radiol 1995; 68:1004.
- Hartsell WF, Murthy AK, Kiel KD, et al. Technique for breast irradiation using custom blocks conforming to the chest wall contour. Int J Radiat Oncol Biol Phys 1990; 19:189.
- Fraass BA, Roberson PL, Lichter AS. Dose to the contralateral breast due to primary breast irradiation. Int J Radiat Oncol Biol Phys 1985; 11:485.
- Kelly CA, Wang XY, Chu JC, Hartsell WF. Dose to contralateral breast: a comparison of four primary breast irradiation techniques. Int J Radiat Oncol Biol Phys 1996; 34:727.
- Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med 2010; 362:513.
- Formenti SC, Truong MT, Goldberg JD, et al. Prone accelerated partial breast irradiation after breast-conserving surgery: preliminary clinical results and dose-volume histogram analysis. Int J Radiat Oncol Biol Phys 2004; 60:493.
- Bieri S, Russo M, Rouzaud M, Kurtz JM. Influence of modifications in breast irradiation technique on dose outside the treatment volume. Int J Radiat Oncol Biol Phys 1997; 38:117.
- Berrang TS, Olivotto I, Kim DH, et al. Three-year outcomes of a Canadian multicenter study of accelerated partial breast irradiation using conformal radiation therapy. Int J Radiat Oncol Biol Phys 2011; 81:1220.
- Shaitelman SF, Kim LH, Grills IS, et al. Predictors of long-term toxicity using three-dimensional conformal external beam radiotherapy to deliver accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys 2011; 81:788.
- Probst H, Griffiths S. Moving to a high-tech approach to the irradiation of early breast cancer: is it possible to balance efficacy, morbidity and resource use? Clin Oncol (R Coll Radiol) 2006; 18:268.
- Smith D, MacDougall N, Monk J, et al. First quinquennial review of intensity-modulated radiotherapy at St Bartholomew's Hospital, London. Clin Oncol (R Coll Radiol) 2010; 22:666.
- O'Donnell H, Cooke K, Walsh N, Plowman PN. Early experience of tomotherapy-based intensity-modulated radiotherapy for breast cancer treatment. Clin Oncol (R Coll Radiol) 2009; 21:294.
- Strnad V, Hildebrandt G, Pötter R, et al. Accelerated partial breast irradiation: 5-year results of the German-Austrian multicenter phase II trial using interstitial multicatheter brachytherapy alone after breast-conserving surgery. Int J Radiat Oncol Biol Phys 2011; 80:17.
- Zannis V, Beitsch P, Vicini F, et al. Descriptions and outcomes of insertion techniques of a breast brachytherapy balloon catheter in 1403 patients enrolled in the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial. Am J Surg 2005; 190:530.
- Benitez PR, Streeter O, Vicini F, et al. Preliminary results and evaluation of MammoSite balloon brachytherapy for partial breast irradiation for pure ductal carcinoma in situ: a phase II clinical study. Am J Surg 2006; 192:427.
- Jeruss JS, Vicini FA, Beitsch PD, et al. Initial outcomes for patients treated on the American Society of Breast Surgeons MammoSite clinical trial for ductal carcinoma-in-situ of the breast. Ann Surg Oncol 2006; 13:967.
- Vicini F, Beitsch PD, Quiet CA, et al. Three-year analysis of treatment efficacy, cosmesis, and toxicity by the American Society of Breast Surgeons MammoSite Breast Brachytherapy Registry Trial in patients treated with accelerated partial breast irradiation (APBI). Cancer 2008; 112:758.
- Smith BD, Arthur DW, Buchholz TA, et al. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys 2009; 74:987.
- American Society of Breast Surgeons, Consensus statement for Accelerated Partial Breast Irradiation www.breastsurgeons.org (Accessed on July 27, 2010).
- Cuttino LW, Keisch M, Jenrette JM, et al. Multi-institutional experience using the MammoSite radiation therapy system in the treatment of early-stage breast cancer: 2-year results. Int J Radiat Oncol Biol Phys 2008; 71:107.
- Arthur DW, Vicini FA. Accelerated partial breast irradiation as a part of breast conservation therapy. J Clin Oncol 2005; 23:1726.
- Vaidya JS, Tobias JS, Baum M, et al. Intraoperative radiotherapy for breast cancer. Lancet Oncol 2004; 5:165.
- Veronesi U, Gatti G, Luini A, et al. Full-dose intraoperative radiotherapy with electrons during breast-conserving surgery. Arch Surg 2003; 138:1253.
- Ivanov O, Dickler A, Lum BY, et al. Twelve-month follow-up results of a trial utilizing Axxent electronic brachytherapy to deliver intraoperative radiation therapy for early-stage breast cancer. Ann Surg Oncol 2011; 18:453.
- Njeh CF, Saunders MW, Langton CM. Accelerated Partial Breast Irradiation (APBI): A review of available techniques. Radiat Oncol 2010; 5:90.
- Gaffney DK, Leavitt DD, Tsodikov A, et al. Electron arc irradiation of the postmastectomy chest wall with CT treatment planning: 20-year experience. Int J Radiat Oncol Biol Phys 2001; 51:994.
- Feigenberg SJ, Price Mendenhall N, Benda RK, Morris CG. Postmastectomy radiotherapy: patterns of recurrence and long-term disease control using electrons. Int J Radiat Oncol Biol Phys 2003; 56:716.
- Spierer MM, Hong LX, Wagman RT, et al. Postmastectomy CT-based electron beam radiotherapy: dosimetry, efficacy, and toxicity in 118 patients. Int J Radiat Oncol Biol Phys 2004; 60:1182.
- Pierce LJ, Butler JB, Martel MK, et al. Postmastectomy radiotherapy of the chest wall: dosimetric comparison of common techniques. Int J Radiat Oncol Biol Phys 2002; 52:1220.
- Lichter AS, Fraass BA, Yanke B. Treatment Techniques in the Conservative Management of Breast Cancer. Semin Radiat Oncol 1992; 2:94.
- Cuzick J, Stewart H, Rutqvist L, et al. Cause-specific mortality in long-term survivors of breast cancer who participated in trials of radiotherapy. J Clin Oncol 1994; 12:447.
- Frazier RC, Kestin LL, Kini V, et al. Impact of boost technique on outcome in early-stage breast cancer patients treated with breast-conserving therapy. Am J Clin Oncol 2001; 24:26.
- Pierce LJ, Moughan J, White J, et al. 1998-1999 patterns of care study process survey of national practice patterns using breast-conserving surgery and radiotherapy in the management of stage I-II breast cancer. Int J Radiat Oncol Biol Phys 2005; 62:183.
- Hunter MA, McFall TA, Hehr KA. Breast-conserving surgery for primary breast cancer: necessity for surgical clips to define the tumor bed for radiation planning. Radiology 1996; 200:281.
- Harrington KJ, Harrison M, Bayle P, et al. Surgical clips in planning the electron boost in breast cancer: a qualitative and quantitative evaluation. Int J Radiat Oncol Biol Phys 1996; 34:579.
- DeBiose DA, Horwitz EM, Martinez AA, et al. The use of ultrasonography in the localization of the lumpectomy cavity for interstitial brachytherapy of the breast. Int J Radiat Oncol Biol Phys 1997; 38:755.
- Messer PM, Kirikuta IC, Bratengeier K, Flentje M. CT planning of boost irradiation in radiotherapy of breast cancer after conservative surgery. Radiother Oncol 1997; 42:239.
- Vicini FA, Sharpe M, Kestin L, et al. Optimizing breast cancer treatment efficacy with intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys 2002; 54:1336.
- Hong L, Hunt M, Chui C, et al. Intensity-modulated tangential beam irradiation of the intact breast. Int J Radiat Oncol Biol Phys 1999; 44:1155.
- CHOICE OF PARTICLES FOR RADIATION THERAPY
- TREATMENT PLANNING
- Primary field
- Regional field
- VIRTUAL (CT-BASED) SIMULATION
- Clinical issues
- WHOLE-BREAST RADIATION THERAPY
- Dose and fractionation
- Approach to the patient with large breasts
- ACCELERATED PARTIAL BREAST IRRADIATION
- External beam radiation therapy
- - Conformal external beam radiotherapy
- - Intensity-modulated radiotherapy
- - Interstitial brachytherapy
- - Intracavitary brachytherapy
- Intraoperative radiation therapy
- Technical considerations
- - Dosing
- - Verification of conformance
- POSTMASTECTOMY RADIATION THERAPY
- REGIONAL NODE RADIATION THERAPY
- RT BOOST
- NOVEL RT PLANNING AND DELIVERY TECHNIQUES