IMPORT HIGH: introduction of image guided breast radiotherapy via a national breast trial


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Jenny Titley1, Judith Bliss1, Charlotte Coles2, Ellen Donovan2, Philip Evans1, Jo Haviland1, Mark Sydenham1, John Yarnold1, IMPORT Trial Management Group3

1Institute of Cancer Research, Sutton, UK, 2Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK, 3NHS, National, UK

Abstract

In around 50% of women with early breast cancer, local tumour recurrence remains a significant hazard despite optimal breast conservation surgery, radiotherapy and adjuvant systemic therapies. IMPORT HIGH tests dose escalated radiotherapy using IMRT in patients undergoing breast conserving surgery who are at a higher than average risk of local recurrence and require a boost dose of radiotherapy.

The importance of using fiducial markers for partial breast radiotherapy has been shown from the NCRN GOLDSEED study and an audit of the use of surgical clips to mark the tumour bed conducted at Addenbrooke’s hospital. The use of surgical clips to achieve this is currently being implemented in the IMPORT LOW trial. For IMPORT HIGH it is also essential to be able to verify the treatment fields to ensure adequate radiation coverage by imaging the tumour bed during treatment. This requires improved localisation and on-treatment verification of breast tissue surrounding the tumour bed. Thus implanted fiducial markers enable accurate targeting of the region at highest risk of recurrence, whilst minimising the dose to normal tissues. Centres will be using gold seeds or surgical clips and appropriate imaging systems to achieve this. Associated with IMPORT HIGH a new study is proposed to evaluate the methods of on treatment verification known as Image guided radiotherapy (IGRT), the IMPORT-IGRT study. We describe the methods used to achieve on treatment verification and their importance to the safe conduct of the IMPORT HIGH trial and to future radiotherapy practice.

In around 50% of women with early breast cancer, local tumour recurrence remains a significant hazard despite optimal breast conservation surgery, radiotherapy and adjuvant systemic therapies. IMPORT HIGH tests dose escalated radiotherapy using IMRT in patients undergoing breast conserving surgery who are at a higher than average risk of local recurrence and require a boost dose of radiotherapy.

The importance of using fiducial markers for partial breast radiotherapy has been shown from the NCRN GOLDSEED study and an audit of the use of surgical clips to mark the tumour bed conducted at Addenbrooke’s hospital. The use of surgical clips to achieve this is currently being implemented in the IMPORT LOW trial. For IMPORT HIGH it is also essential to be able to verify the treatment fields to ensure adequate radiation coverage by imaging the tumour bed during treatment. This requires improved localisation and on-treatment verification of breast tissue surrounding the tumour bed. Thus implanted fiducial markers enable accurate targeting of the region at highest risk of recurrence, whilst minimising the dose to normal tissues. Centres will be using gold seeds or surgical clips and appropriate imaging systems to achieve this. Associated with IMPORT HIGH a new study is proposed to evaluate the methods of on treatment verification known as Image guided radiotherapy (IGRT), the IMPORT-IGRT study. We describe the methods used to achieve on treatment verification and their importance to the safe conduct of the IMPORT HIGH trial and to future radiotherapy practice.