1. חידושים בטיפול קרינתי לשד: קרינה מקוצרת דיאנה מצייבסקי, מחלקה אונקולוגית, מכון קרינה 24.04.13

2. External beam radiotherapy Whole Breast Radiotherapy (WBRT)

3. Standard tangential field

5. Simulation

7. Radiotherapy For Breast Cancer Increases Heart Disease Risk N Engl J Med 2013; 368:1055-1056March 14, 2013

9. FATIGUE

10. RADIATION DERMATITIS

12. Changes in breast appearance

13. Rib fractures

14. LYMPHEDEMA

15. Conventional Whole breast Radiotherapy plan Boost 25 fractions8 fractions 2Gy per fraction

16. FASTER, FASTER!

17. The UK standardisation of Breast Radiotherapy (START)- Trial A and B of Radiotherapy hypofracyionation for treatment of early breast cancer: a randomized trial

18. Hypofractionation «START» «START» 25 х 2 Gy = 15 х 2,67 Gy 25 х 2 Gy = 15 х 2,67 Gy

19. START Randomization 50 Gy- in 25 fractions 40 Gy- in 15 fraction 11051110

20. Hypofractionated Radiation Therapy for Breast Cancer RANDOMIZATION 50 Gy in 25 fractions 42,5 Gy in 16 fractions 612622

21. Shorter fractionation schedules: ■ No difference in local recurrence ■ No difference in overall survival ■ A significant decrease in acute radiation toxicity ■ No difference in late skin toxicity, ischemic heart disease, or rib fractures ■ No difference in breast appearance

22. What still is questionable? The effect not clear in large breasts The effect not clear in large breasts The safety of shorter course in combination with chemotherapy or monoclonal antibodies (Herceptin, Pertuzumab)? The safety of shorter course in combination with chemotherapy or monoclonal antibodies (Herceptin, Pertuzumab)? The “boost” issue The “boost” issue What about treatment for regional lymph nodes ? What about treatment for regional lymph nodes ?

23. Reasonable approach (supported by ASTRO/ESTRO) Women >50y Women >50y Tumor < 5 cm Tumor < 5 cm Node negative Node negative Without prior chemo? Without prior chemo? Boost? Boost?

24. Partial Breast Irradiation

25. Rationale for Partial Breast Irradiation  ~ 80% of local recurrences after conservative surgery + WBRT occur in tumor bed region “Elsewhere” recurrences in breast rare after CS +/- WBRT “Elsewhere” recurrences in breast rare after CS +/- WBRT

26. Partial Breast Radiotherapy Interstitial Breast Brachytherapy 5 days-2 daily fractions Mammosite

27. Intra-operative radiotherapy

28. External Beam Partial Breast Irradiation

29. PBI: Where are we? While several preliminary studies have had excellent 5-yr results, they contain only small numbers of highly-selected pts While several preliminary studies have had excellent 5-yr results, they contain only small numbers of highly-selected pts NSABP B-39/RTOG : 10 yrs for data to mature NSABP B-39/RTOG : 10 yrs for data to mature

30. Consensus Statements on PBI: American Society of Breast Surgeons and American Brachytherapy Society. PBI “off protocol” should be limited to pts: age > 50 IDC histology or DCIS Tumor < 2 cm (including DCIS) Margin > 2 mm Lymph node - negative

31. Partial Breast Irradiation: Not Yet the Standard-of- Care