Prone APBI

[SneakyBooger]

One of the Ivory Towers is instructing APBI patients to "make sure you are being treated in the prone position".

A recent pt whose tumor bed extends to the pectoralis where prone pushed the heart towards the PTV was informed of such.

I instructed the patient that I recommend against prone in her situation and she understood and agreed.

I don't see compelling data that prone APBI provides a clinically significant benefit in all patients.

What am I missing here? Thoughts?

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[communitydoc13]

I'd like to know as well. My experience with prone breast treatment.

1. Reproducibility and verification of position is always more challenging.
2. At times, prone in intrinsically inferior to supine for heart dose
3. Prone is essentially always a bit of a partial breast set-up
4. The patients who may benefit from prone (very large, pendulous breasts that relax laterally when supine) are often not comfortable in the prone position.

 

[Ray D. Ayshun]

One of the Ivory Towers is instructing APBI patients to "make sure you are being treated in the prone position".

A recent pt whose tumor bed extends to the pectoralis where prone pushed the heart towards the PTV was informed of such.

I instructed the patient that I recommend against prone in her situation and she understood and agreed.

I don't see compelling data that prone APBI provides a clinically significant benefit in all patients.

What am I missing here? Thoughts?

I thought the whole point of apbi was to give even less off target dose, which truth be told us already pretty minimal. Beyond that, I do imrt when doing apbi, and was under the impression that prone setup is less good for reproducibility. Farbeit from me to argue with an academic but it sounds like another made up thing. It is a tale, told by an academic breast rad onc, full of sound and fury, signifying nothing. Or so I'll tell myself for now

 

[deleted1116990]

Was it Mayo?

I got a patient like this too. Demanded prone (left whole breast) as they had convinced her anything else was unsafe. Could not be convinced otherwise and left. I do DIBH on virtually everybody.

Huge WTF with however these patients are being educated.

 

[fiji128]

Prone breast is great with many dosimetric advantages due to the decreased separation and with the breast tissue falling away from the chest wall. I do a good amount and have found reproducibility and patient comfort are not real issues with experienced therapist. However, if you have a lumpectomy cavity that is right on the muscle and especially with left sided disease, prone may not be a slam dunk.

 

[deleted1116990]

Prone breast is great with many dosimetric advantages due to the decreased separation and with the breast tissue falling away from the chest wall. I do a good amount and have found reproducibility and patient comfort are not real issues with experienced therapist. However, if you have a lumpectomy cavity that is right on the muscle and especially with left sided disease, prone may not be a slam dunk.

I have no problem with prone in many cases, but I don't have the equipment to offer it. The problem is that somebody at Mayo is going around impressing upon patients that supine breast treatment is quackery. I suspect they know it's relatively uncommon in the community and will result in patients coming back for treatment there.

 

[BobbyHeenan]

There is an older PRO paper that suggested DIBH often (?more often?) beats breast prone for heart sparing. Someone out there can probably find that reference.

I do both prone and supine but prefer DIBH supine for fit patients. Obviously large cup size patients can sometimes have prone benefit so I have that set up available.

It cracks me up how dogmatic (?or marketing?) people can be on breast. There are so many ways to get good breast treatment and breast anatomy is so variable. I agree with sentiments regarding prone set up...can be dicey at times IMO. Some people swear it isn't but at the academic center and out in practice my experience is it certainly can be dicey.

link:

DEFINE_ME

 

[fiji128]

I think a good quality prone breast board, ie Civco, cost about $10,000. Should be standard equipment in community clinics considering the volume of stage I breast that is treated. The ivory tower place claiming to their patients that non prone treatment is quackery is idiotic. For the vast majority of adjuvant breast, assuming competent care, convenience is really the most important thing.

 

[HolySmokes]

I recently had a patient seen at MSKCC. They needed standard tangents for left breast cancer and MSKCC told them they absolutely could not get radiation locally if we didn't offer prone. I told the patient I wasn't going to offer that because we have DIBH and it's much more reproducible. So, they flew to NYC for their 4 weeks of treatment...

 

[SneakyBooger]

LIVI only allowed supine.

 

[Radonc 2013]

I think a good quality prone breast board, ie Civco, cost about $10,000. Should be standard equipment in community clinics considering the volume of stage I breast that is treated. The ivory tower place claiming to their patients that non prone treatment is quackery is idiotic. For the vast majority of adjuvant breast, assuming competent care, convenience is really the most important thing.

DIBH and Prone breast board should let you battle the nearby academic center temporarily, until they realize you have both, and start telling patients that treatment on a MR Linac or with protons are the only acceptable methods for breast RT

 

[SneakyBooger]

This is from a recent publication. It may be a "typical APBI plan" but not sure it is necessarily a "typical APBI patient".

 

[SneakyBooger]

And there is this from the Royal Marsden study:
doi:10.1016/j.radonc.2010.05.014

 

[evilbooyaa]

Never done it, never offered it, not sure why it's necessary. Ivory towers gotta pull out the gimmicks for breast patients. If you have DIBH for a L-breast you're fine. Most APBI, IMO, doesn't really need DIBH.

 

[RO28]

having never done APBI and getting ready to plan my first case, do you request SBRT or IMRT auth? Seems like we could do SBRT based on the florence fractionation?

 

[metallica81788]

Oh not the SBRT thing again...

I do IMRT. Have never had an issue.

 

[radiaterMike]

For most insurer's policies I don't think SBRT is covered for APBI - even with some commercial systems specific for this (e.g., GammaPod). Justifying billing for SBRT would be challenging (i.e. neither NCCN or ASTRO's APBI statement address SBRT). I think the billing for IMRT for 8 fractions ~ SBRT in 5 fractions (though I don't know the technical/profressional breakdown of this) so the difference in SBRT vs 5-Fx IMRT is probably not that much.

 

[RO28]

Did I open a can of worms?

IMRT it is.

 

[evilbooyaa]

having never done APBI and getting ready to plan my first case, do you request SBRT or IMRT auth? Seems like we could do SBRT based on the florence fractionation?

I request SBRT. If it is denied I accept 5Fx IMRT. You won't score on the shots you don't take. See business forum for a longer discussion about this.

 

[TheWallnerus]

having never done APBI and getting ready to plan my first case, do you request SBRT or IMRT auth? Seems like we could do SBRT based on the florence fractionation?

If you’re requesting auth, do IMRT for plan and tx. If you’re not requesting auth (ie in a Medicare case where preauth doesn’t apply), plan IMRT and bill SBRT because the treatment most closely matches SBRT Medicare criteria.

YMMV

 

[medgator]

If you’re requesting auth, do IMRT for plan and tx. If you’re not requesting auth (ie in a Medicare case where preauth doesn’t apply), plan IMRT and bill SBRT because the treatment most closely matches SBRT Medicare criteria.

YMMV

Agree. You've got the high dose per fraction, the image guidance/immobilization etc

 

[sniperjoe]

Agree it's Ivory Tower hogwash to state prone is the best treatment for all patients. However, I've been doing it for a long time and kind of prefer it whenever doing APBI. Some advantages to prone partial breast (for the right patient, i.e. Cup size >B)
(1) ALARA contralateral breast dose, lung dose, and heart dose***. (The exception is of course tumors located against the chest wall in which the heart falls foward - those cases I usually do DIBH)
(2) Eliminates respiratory movement during IMRT (can also be accomplished with DIBH)

 

[RO28]

If you’re requesting auth, do IMRT for plan and tx. If you’re not requesting auth (ie in a Medicare case where preauth doesn’t apply), plan IMRT and bill SBRT because the treatment most closely matches SBRT Medicare criteria.

YMMV

Ngl, I really just want the SBRT OTV because I'm pro fees only #RVUlife.