1. Suggested guidelines for appropriate patient selection for patients undergoing Accelerated Partial Breast Irradiation at DMC. Tonya Echols Cole, MD

2. Patient Evaluation Multidisciplinary; before surgery – Breast Surgeon – Radiation Oncologist – Medical Oncologists

3. Types of APBI Interstitial Intraoperative – Electron – 50 Kv Balloon cavitary – Mammosite – Contura – Savi External Beam – 3D conformal – IMRT

4. Current Guidelines- Old ASBS - 2005 ABS - 2007 European Collaborative Group - 2009 ACRO - 2008 ASTRO- 2009

5. Additional Studies At least 5 randomized trials – Short follow-up – Outdated or nonstandard technique – Lack of power At least 41 non randomized trials – Many with at least 10 year follow-up

6. 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

7. 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

8. 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

9. 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 +

10. 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

11. 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 -

12. 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.

13. Acceptable Age > 50 Size < 3 cm HistologyAll invasive subtypes and DCIS ERPositive or negative MarginsNegative LVI Not present Nodal status negative

14. 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 +

15. Future Directions Recommendations should be updated annually as new results from prospective randomized trials are released.