Phase II Study of MRI-Based Preoperative Accelerated Partial Breast Irradiation
Phase: NA
Conditions: Breast Cancer
Sponsor: Medical College of Wisconsin

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 1 of 39 
 
A PHASE II STUDY OF MRI-BASED PRE-OPERATIVE ACCELERATED 
PARTIAL BREAST IRRADIATION 
Funded by the Dr. Nancy Laning Sobczak Award for Breast Cancer 
CT.GOV#02728076 
Principal Investigator and Radiation Oncology Co-
Chair 
Adam Currey, MD 
Assistant Professor 
Department of Radiation Oncology 
Medical College of Wisconsin 
8701 W. Watertown Plank Rd 
Milwaukee, WI 53226 
(414) 805-4462 
acurrey@mcw.edu 
 
 
 
Co-Principal Investigator 
Carmen Bergom, MD, PhD 
Assistant Professor 
Department of Radiation Oncology 
Medical College of Wisconsin 
8701 W. Watertown Plank Rd 
Milwaukee, WI 53226 
(414) 805-4450 
cbergom@mcw.edu 
 
 
Co-Investigators 
Joseph Bovi, MD 
Associate Professor 
Department of Radiation Oncology 
Medical College of Wisconsin 
8701 W. Watertown Plank Rd 
Milwaukee, WI 53226 
(414) 805-4476 
jbovi@mcw.edu 
 
 
Tracy R. Kelly 
Assistant Professor 
Department of Radiation Oncology 
Medical College of Wisconsin 
8701 W. Watertown Plank Rd 
Milwaukee, WI 53226 
(414) 805-4462 
tkelly@mcw.edu 
 
Radiology Co-Chair 
Anubha Wadhwa, MD 
Assistant Professor 
Department of Radiology 
Medical College of Wisconsin 
8701 W. Watertown Plank Rd 
Milwaukee, WI 53226 
(414) 805-0298 
awadhwa@mcw.edu 
 
Surgical Co-Chair 
Amanda Kong, MD, MS 
Associate Professor 
Division of Surgical Oncology 
Medical College of Wisconsin 
8701 W. Watertown Plank Rd 
Milwaukee, WI 53226 
(414) 805-5815 
akong@mcw.edu 
Medical Physics 
Eric Paulsen, PhD 
Assistant Professor 
Department of Radiation Oncology 
Medical College of Wisconsin 
8701 W. Watertown Plank Rd 
Milwaukee, WI 53226 
(414) 805-0562 
epaulson@mcw.edu 
 
 
 
Pathology Co-Chair 
Julie Jorns, MD 
Associate Professor 
Department of Pathology 
Medical College of Wisconsin 
8701 W. Watertown Plank Rd 
Milwaukee, WI 53226 
(414) 805-8454 
jjorns@mcw.edu 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 2 of 39 
 
Biostatistics 
Mie-Jie Zhang, PhD 
Professor 
Department Biostatistics and Institute for Health 
and Society 
Medical College of Wisconsin 
8701 W. Watertown Plank Rd 
Milwaukee, WI 53226 
(414) 456-8375 
meijie@mcw.edu 
 
 
 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 3 of 39 
 
TABLE OF CONTENTS 
 
1.0 
INTRODUCTION  
 
 
 
 
 
 
 
 
5 
 
2.0 
OBJECTIVES  
 
 
 
 
 
 
 
 
10 
 
3.0 
PATIENT SELECTION  
 
 
 
 
 
 
 
11 
 
4.0 
PRE AND POST TREATMENT EVALUATIONS/MANAGEMENT   
 
13 
 
5.0 
REGISTRATION PROCEDURES  
 
 
 
 
 
 
14 
 
6.0 
RADIATION THERAPY  
 
 
 
 
 
 
 
15 
 
7.0 
SYSTEMIC THERAPY  
 
 
 
 
 
 
 
20 
 
8.0 
SURGERY AND POST-OPERATIVE TREATMENT  
 
 
 
21 
 
9.0 
PATHOLOGIC EVALUATION AND 
GENETIC EVALUATION OF TISSUE SPECIMENS  
 
 
 
22 
 
10.0 
PATIENT ASSESSMENTS   
 
 
 
 
 
 
25 
 
11.0 
STATISTICAL CONSERATIONS  
 
 
 
 
 
 
27 
 
REFERNCES  
 
 
 
 
 
 
 
 
 
29 
 
APPENDIX I   
 
 
 
 
 
 
 
 
 
36 
 
APPENDIX II.  
 
 
 
 
 
 
 
 
 
39 
 
APPENDIX III  
 
 
 
 
 
 
 
 
 
40 
 
APPENDIX IV. 
 
 
 
 
 
 
 
 
 
41 
 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 4 of 39 
 
STUDY SCHEMA 
A PHASE II STUDY OF MRI-BASED PRE-OPERATIVE ACCELERATED 
PARTIAL BREAST IRRADIATION 
 
 
 
 
Breast 
Conserving 
Surgery 
At least 35 
days after 
radiation 
Gene 
expression 
profile in final 
specimen 
Pre-RT 
Diagnostic 
Breast MRI 
Gene 
expression 
profile on 
biopsy 
 
Early Stage Breast 
Cancer Patients 
 
 Age ≥40 
Tumors ≤3cm 
Estrogen Receptor 
positive 
Clinically node negative 
Post-RT, 
Breast MRI  
At least 28 
days after 
radiation 
E 
N 
R 
O 
L 
L 
Pre-operative 
Accelerated Partial 
Breast Irradiation to 
tumor with margin 
using MRI-based 
treatment planning 
 
30Gy in 5 fractions 
of 6Gy 
See Section 6.0 for details of radiation therapy 
 
Patient Population:  (See Section 3.0 for Eligibility and additional requirements 
Stage I-IIA, Node negative breast cancer eligible for breast conservation.  
 
 
 
Required Sample Size:  40 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 5 of 39 
 
1.0 INTRODUCTION 
1.1 Rationale for Pre-Operative Accelerated Partial Breast Irradiation 
Each year, approximately 200,000 women are diagnosed with breast cancer, including more than 
4,000 new cases in the state of Wisconsin. More than 40,000 women die of the disease each 
year. With the consistent use and availability of screening by mammogram and additional imaging 
techniques, the majority of these women are diagnosed with localized disease that is amenable 
to successful treatment. For these women there are two main treatment options: (1) mastectomy, 
removal of the breast, or (2) breast conserving therapy, consisting of lumpectomy and radiation 
therapy. The goals of breast conservation are to eradicate the cancer from its site of origin while 
maintaining a cosmetically acceptable breast. Several large prospective randomized trials have 
shown equivalent overall survival and breast cancer specific survival when comparing 
mastectomy and lumpectomy with radiation therapy (1-7). 
Traditionally, women who undergo lumpectomy then receive radiation therapy to the entire breast 
for three to six weeks. Unfortunately, this protracted treatment course has led some patients to opt 
for mastectomy over breast conserving therapy. However, emerging data suggests that treatment 
of the whole breast may not be necessary in select patient groups and that shorter, less costly 
treatment regimens may be possible. When radiotherapy is omitted from breast conserving 
therapy, most in-breast recurrences occur near the initial site of disease at the lumpectomy cavity. 
Accelerated partial breast irradiation (APBI) is a technique that delivers radiation to that volume of 
breast tissue at the highest risk of recurrence. Because a smaller volume of tissue is treated, it is 
possible to deliver a higher radiation dose with each treatment and the treatment course is reduced 
to five days (8-10).  
The largest reported series of APBI with the most mature follow-up have utilized brachytherapy as 
the method of radiation delivery (54). This involves surgically implanting a device in the breast and 
then placing a radioactive source inside that device for a period of time to deliver dose. The 
invasive nature of brachytherapy, lack of wide-spread expertise in its use for breast cancer, as well 
as improved imaging technology has led to the development of APBI using external beam 
radiotherapy. While initial phase II data has been promising (26), more recent data has raised 
concerns regarding the toxicity profile of this technique (25,27,28). One prospective phase III study 
comparing conventional whole breast irradiation with APBI using external beam radiotherapy 
reported comparable rates of local control, but increased rates of breast fibrosis, breast pain, and 
adverse cosmetic result for those receiving APBI (55). This has led many to question external 
beam-based APBI as a viable treatment alternative to more conventional radiation treatment 
schedules. Improving the side-effect profile of this treatment might lead to more patients selecting 
breast conservation with external beam-based APBI as the radiation treatment method, Some 
estimates have reported that more widespread use of APBI in appropriate patients could result in 
more patients selecting breast conservation and savings in health care costs that exceed $7.5 
million per 1000 patients treated. 
The current standard practice of delivering radiation therapy post-operatively has had two major 
drawbacks: (1) inaccurate targeting, and (2) inability to measure the radiation response in the 
primary tumor. The target volume for post-operative APBI has been the tissue surrounding the 
lumpectomy cavity. However, this cavity may not necessarily direct the radiation toward the highest 
risk area of the breast around the tumor as tumors can be peripherally located in the resection 
specimen (see Figure 1). This results in the need for a large margin of normal breast tissue (e.g., 
1.5 cm) to be treated. In order to take into account the area at risk for microscopic residual disease, 
this volume must then be expanded. One must also account for patient motion during treatment, 
as well as variation in patient positioning from day to day. This requires additional expansion of the 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 6 of 39 
 
target 
volume 
(13).  
Furthermore, 
due 
to 
the 
variations in daily patient setup 
on the treatment table and 
respiratory 
motion 
during 
radiation, an additional margin 
around the lumpectomy cavity 
has to be used (e.g., 1.0 cm for 
a total of 2.5 cm). This results in 
more normal tissue irradiated to 
high 
dose 
than 
might 
be 
necessary (13). It is well-
documented that larger the area 
of breast tissue that receives 
definitive doses of radiation, the 
higher the risk for fibrosis of the 
tissue (11-12). These large 
margins also limit the patient 
eligibility for APBI - if the size of 
the breast is small in relation to 
this large target volume, APBI 
cannot be done safely (29,30). 
The current clinical practice of breast conserving therapy, including APBI, has not taken advantage 
of the significant advances in breast imaging to improve its geometric accuracy. In the current 
study, we propose treating well-selected patients with APBI pre-operatively. Pre-operative RT 
would target more precisely the area at risk for microscopic disease, and also result in less breast 
tissue receiving RT (Figure 1C).   
Other potential benefits to pre-operative radiation include improved rates of margin negative 
resection and a reduced need for re-excision. Finally, with radiotherapy delivered prior to 
surgery, the tissue receiving the highest dose of radiation will then be surgically removed. Pre-
operative radiation has been used in other tumor sites such as sarcoma, rectal, pancreatic, and 
lung cancers and has been shown to improve the rates of margin negative resections (16-22). In 
some of these disease sites, this has decreased late morbidity compared to post-operative 
treatment (16,18). We anticipate similar results in this population of early stage breast cancer as 
the portion of the breast receiving the highest dose of radiation will be removed surgically. It is 
anticipated that this factor will lead to additional reductions in breast fibrosis and improved 
cosmetic outcomes.  
Pre-operative treatment also allows for assessment of tumor response to radiotherapy in vivo, 
something that has not been studied to any extent as most breast radiotherapy is delivered in 
the post-operative setting. Response to pre-operative chemotherapy has been shown to be 
predictive of patient outcome, and it is possible that tumor response to radiation may offer similar 
prognostic information. 
 
1.2 Rationale for MRI-based Pre-operative Accelerated Partial Breast Irradiation and other 
Advanced Imaging Techniques 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 7 of 39 
 
Traditionally, most external-beam based APBI has been 
delivered using CT-based treatment planning. However, on 
traditional CT imaging, the precise size and shape of the 
surgical cavity can be difficult to delineate. This is 
exacerbated by the fact that at times, normal breast tissue 
can have an appearance similar to post-surgical changes.  
The use of MRI will ensure the tumor can be well visualized 
and targeted with the radiation, resulting in smaller volume 
of breast tissue to be treated (14-15). It has been well-
documented that MRI has a higher sensitivity than 
mammography in detecting and characterizing breast 
cancer (56,57). In particular, breast MRI is an excellent tool 
for determining gross tumor extent and for detecting small 
tumor in dense breasts (14,15). Furthermore, MRI can 
provide functional and biological information, further 
improving target definition and opening doors for novel 
biologically conformal RT strategies. MRI has high 
sensitivity for detecting cancer and for assessing the extent 
of disease in the breast prior to surgery. Therefore, 
radiation should be more ideally targeted based on MRI-
defined pre-operative disease location versus surgical 
cavity location. In CT-based treatment planning, the target 
volume typically includes the seroma cavity and any clips left 
by the breast surgeon. When used for radiation delivery, 
MRI in the post-operative setting reduces the volume of 
normal breast tissue that is treated compared to CT-based 
treatment alone (35, also see Figure 2). In pre-clinical 
studies, MRI-based planning in the pre-operative setting 
has also been shown to decrease the volume of targeted 
breast tissue (29,30). This is significant, as series of APBI 
from FH/MCW and other institutions demonstrate that late 
toxicity of treatment and adverse cosmetic outcome are correlated with increasing volume of 
normal breast tissue that is irradiated (24). Consequently, reducing the volume of irradiated 
breast tissue by utilizing MRI identification of disease, as well as treatment in the pre-operative 
setting, would be expected to result in improved cosmetic outcomes and reduced late toxicity. 
In traditional CT-based imaging, the contrast observed between structures is based on variations 
in density. Because soft tissue structures have similar densities, it can be difficult to precisely 
define borders of a given structure. However, subtle differences in tissue density can be better 
observed when the images are produced using photons with a lower energy spectrum. The result 
is better spatial resolution of images, and the technique is known as Dual-Energy CT. Even when 
MRI is used for radiation treatment planning, it is still necessary to obtain a CT simulation so that 
the radiation beam can be appropriately modeled. In order to optimize target definition for pre-
operative APBI, patients enrolled on this protocol will have a Dual Energy CT performed as part 
of their treatment planning scans.  
1.3 Use of Additional Advanced Radiation Delivery Techniques 
Previous studies have demonstrated that prone APBI in the post-operative setting utilizing daily 
CT-image guided radiation therapy allows for reduction in the target volume, due to the decrease 
in daily positioning uncertainty provided by the daily CT image guidance (24). CT-guided adaptive 
Fig. 2: Post-lumpectomy prone 
CT images (top). The brown 
contour demonstrates the 
lumpectomy cavity.  MRI (STIR) 
image registered with the CT 
(bottom)  shows the lumpectomy 
cavity contour (magenta) 
demonstrating that the volume is 
smaller than the same target 
defined on CT (brown contour). 
As shown, treatment of the CT-
based volumes would treat a 
larger volume of breast tissue 
than is necessary

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 8 of 39 
 
treatment delivery will be used to account for changes during the course of treatment (61). 
Patients treated on this protocol will preferentially be treated in the prone position if the size of the 
breast allows. One of the inherent challenges in using MRI for breast cancer therapy has been 
extrapolating MRI findings attained in the prone position to the surgery and/or RT typically carried 
out in the supine position. We have previously developed both whole breast irradiation and ABPI 
in the prone position and have reported that the target coverage, normal-tissue sparing, and 
clinical outcomes with prone treatment are comparable to those treated supine (24,64). In 
addition, it has been shown by us and others (24, 62-64) that the prone set up can (1) increase 
dose homogeneity in the breast for large, pendulous, breasts, (2) reduce respiratory motion, and 
(3) improve sparing of lung and heart. Combining the accuracy of MRI in assessing the extent of 
tumor, the precision of daily CT-guided targeting, and treatment in the prone position, will allow 
the proposed pre-operative APBI to deliver effective dose to the gross tumor while minimizing the 
irradiation of healthy tissues. 
1.4  Changes in Tumor Gene Expression As a Result of Radiotherapy 
Progress in elucidating the molecular basis of breast cancer, including the delineation of 
‘molecular subtypes,’ has allowed for such treatment breakthroughs as anti-estrogen and Her2 
targeted therapies. Molecular biology is also shaping the current approach to both surgical (90) 
and systemic therapy (91). The use of molecular information has become commonplace in 
directing systemic therapy decisions in breast cancer using gene expression profile scores (78), 
such as OncotypeDX (79), marking a significant advancement in medical oncology. Unfortunately, 
no similar use of molecular information has been utilized to better direct the use of radiation 
therapy for invasive breast cancer. Rather, improvements in RT have been chiefly technological, 
with more accurate targeting and delivery (74). Recent progress has been made with the 
development of a gene expression model of tumor radiosensitivity based upon in vitro data, and 
though it has not been fully validated, this approach has proved useful in evaluating outcomes in 
retrospective datasets, including two breast cancer studies (75-77). While significant, this 
approach is still limited in that it does not account for tumor behavior in vivo and has been limited 
to retrospective analysis of post-operative radiation. Recent data from a Phase I pre-operative 
single-fraction APBI study showed expression of genes regulating immunity and cell death were 
seen in response to radiation (94). We hypothesize that altered gene expression patterns will be 
seen in patients who have enhanced radiation responses. 
1.5  Imaging Changes after Radiation Therapy 
MRI has been an important tool for measuring the extent of disease prior to pre-operative 
chemotherapy and the amount of response afterwards. In contrast, information on MRI changes 
associated with radiation therapy for breast cancer is lacking. Diffusion-weighted MRI holds 
promise for use as a cancer treatment response biomarker as it is sensitive to macromolecular 
and microstructural changes occurring at the cellular level that can be detected earlier than 
anatomic changes. These imaging changes have been studied as predictors of response to 
radiation in other disease sites and as a response to pre-operative chemotherapy in breast 
cancer, studies on radiation-induced changes for breast cancer is lacking. (97) A phase I study 
of high dose single fraction APBI demonstrated evidence of dose-dependent changes in vascular 
permeability in response to radiation (94).  Studying the MRI changes that occur after radiation 
treatment will lay the important groundwork for future studies in which MRI can be used to tailor 
pre-operative radiation dose delivery based on response and predict for patients whose disease 
has responded well to treatment. Patients enrolled on this study will be required to undergo 
diagnostic MRI prior to enrollment. A second diagnostic scan will be performed at least four 
weeks after radiation so comparisons can be made to pre-treatment scans. Specifically, changes 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 9 of 39 
 
in diffusion weighted imaging and dynamic-contrast enhancement will be studied and correlated 
with pathologic response and local control. 
1.6  Post-Operative Complications and Study Endpoints 
One potential disadvantage of pre-operative radiation therapy is the possibility of an increased 
rate of post-operative complications. With the use of pre-operative radiation, a small, but 
acceptable increase in post-operative complications was observed in phase III studies 
comparing pre- versus post-op radiation in patients with rectal cancer and soft-tissue sarcoma 
(16, 18). Consequently, the aim of this phase II study will be to demonstrate safety of pre-
operative APBI and the primary endpoint will be a comparison of post-operative complications 
with historical controls. The complications that will be tracked will include infection, wound 
dehiscence, hematoma, symptomatic seroma requiring intervention, and need for hospitalization 
or a second breast surgery (excluding those done for inadequate surgical margins).  
In this study, it is anticipated that the most common post-operative complications will be infection 
and formation of a symptomatic seroma. This is based on a Phase I study from Horton et.al. that 
used a single large fraction of radiation therapy prior to breast conserving surgery. In that trial, 
the most common post-operative complications were infection (6%) and seroma formation. 
(32%) (94). Often times, these two complications can be seen in the same patient. While the 
Horton study did not report on individual patients who may have had both a seroma and infection, 
the number reported for seroma (32%) will be used as the historical control on this study. 
Historically, rates of post-operative infections for breast conserving surgery in the absence of 
pre-operative radiation therapy have ranged from 1-5%. Post-operative seroma formation is 
somewhat more difficult to quantify because these are often asymptomatic. In a series by 
Boostrom et.al. including 167 patients treated with breast conserving surgery, the rate of clinically 
significant seroma formation (i.e. requiring drainage or some other intervention) was 6% (102). 
Hence, we anticipate that the rates of post-operative complications will exceed those rates, but 
with the long-term benefits described in previous sections of this introduction. 
We anticipate that the rate of post-operative complications on this study will be more favorable 
than those reported by Horton et.al. On this study, the radiation dose and fractionation schedule 
will be much different than that used by Horton et.al. This regimen has been shown to be safe 
and effective in a recent phase III study in the post-operative setting. (95). Fractionating the dose 
allows normal tissues time to repair sublethal radiation injury. This would likely result in a lower 
rate of post-operative complications.  
On the other hand, there are factors on this trial that may result in a higher rate of post-operative 
complications than anticipated. On this study, the interval between radiation and surgery is 
longer on this study than that reported on the Horton study (surgery within 10 days of radiation 
versus at least 35 days after radiation). This longer interval was selected based on recent data 
in the literature for pre-operative treatment for rectal cancer. In this disease site, waiting longer 
for surgery allows for improved tumor regression, improving the rate of margin negative 
resection, and allowing for a smaller resection. In the case of rectal cancer, this translates to 
sphincter preservation but may translate to an improved cosmetic result in the case of breast 
conserving surgery. These benefits have also translated to an improvement in disease-free 
survival for patients with rectal cancer (101). However, the longer interval from radiation to 
surgery may also lead to a slight, but tolerable increase in post-operative complications. It is 
anticipated that the reasons for a lower post-operative complication rate will dominate on this 
study. But given the potential for a higher rate than expected, the rate of the most common 
complication reported on the Horton study will be used as the historical control. 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 10 of 39 
 
1.7  Conclusions 
Pre-operative APBI utilizing MRI-based treatment planning could improve the toxicity profile of 
breast conservation therapy while maintaining excellent rates of local control and low rates of 
post-operative complications. This strategy also has the potential to increase the proportion of 
women who are eligible for APBI and to allow determinants of radiation responses in breast 
cancer to be elucidated. If this study meets the endpoints outlined with respect to safety, it could 
serve as the blueprint for future studies utilizing pre-operative MRI-based APBI. The 
translational component of this study will serve as a baseline to guide future studies in pre-
operative radiation therapy. It will form a basis for testing biologic agents and 
immunomodulators that could potentiate the effects of radiation and further improve pathologic 
response rates. The imaging correlates of this study will also aid in the development of future 
treatment protocols. By better understanding the imaging changes after radiotherapy, it will be 
possible to design radiation treatment regimens that are based on tumor response during a 
treatment course, a type of treatment delivery possible using MRI-based radiation delivery. With 
FH/MCW having recently been selected as one of 7 sites in the world to obtain an MR-Linear 
Accelerator, this proposal will lay the groundwork to optimize the clinical application of this 
technology and will further position the institution as a leader in the provision of such treatment. 
2.0 OBJECTIVES 
2.1  Primary  
Determine post-operative complication rates following pre-operative APBI in patients with early 
stage breast cancer and compare these with historical controls, thus demonstrating the safety of 
this treatment modality. 
2.2 Secondary 
2.2.1 Measure rates of breast fibrosis and pain for patients treated with APBI and 
compare with historical controls of patients treated with post-operative APBI. 
 
2.2.2      Collect data on cosmetic outcomes for patients treated with pre-operative APBI 
 
2.2.4 Measure rates of need for re-excision because of a close or positive margin after 
pre-operative APBI. 
2.2.5 Record long term outcomes of local recurrence rates and overall survival of 
patients treated with this modality. 
2.2.6 Demonstrate the feasibility of MRI-based treatment planning for pre-operative 
APBI and compare dosimetric data from treatment planning with patients treated on a 
previous institutional post-op APBI protocol.  
2.2.7  Study changes in MRI imaging from pre-treatment evaluation, treatment planning, 
and pre-surgical imaging and correlate those changes to pathological response.  
2.2.8  Measure changes in tumor gene expression and immune response to radiation 
therapy and correlate this with pathologic response.  
 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 11 of 39 
 
3.0 PATIENT SELECTION 
3.1 Conditions for Patient Eligibility 
3.1.1 Pathologically proven diagnosis of invasive breast cancer, clinically stage I-II, 
planning for breast conserving surgery 
 
3.1.2 The patient must be female 
 
3.1.3 The patient must meet the following criteria 
• 
Age ≥40 years 
• 
Tumor size no greater than 3.0cm by ultrasound 
• 
Estrogen receptor positive 
• 
Patients with both her2 positive and her2 negative tumors are eligible 
• 
Modified Bloom-Richardson Grade 1-3 is allowed 
• 
Unifocal disease 
• 
Invasive carcinoma diagnosed by core needle biopsy (including invasive 
ductal, papillary, tubular, mammary or medullary carcinoma) within 90 days 
prior to enrollment 
• 
Clinically node negative both by physical exam and by ultrasound or MRI. 
All enlarged or abnormal appearing lymph nodes must be biopsied. 
• 
Zubrod/ECOG performance status 0-2 or Karnofsky 70-100 
3.1.4 Study entry must be within 90 days from initial diagnosis of breast cancer 
3.1.5 Appropriate stage and pre-treatment evaluation for protocol entry, including no 
clinical evidence for distant metastases, based upon the following minimum diagnostic 
workup: 
• 
History/Physical examination, including breast exam (inspection and 
palpation of the breasts) with documentation of weight and Zubrod/ECOG 
Performance Status of 0-2 or Karnofsky Performance Status 70-100 within 
60 days prior to study entry 
• 
Complete Metabolic Panel within 60 days prior to study entry 
• 
Right and left mammography within 60 days of diagnostic biopsy 
establishing diagnosis. A breast MRI may also substitute for the 
mammogram if necessary. 
• 
Evaluation of the axilla by ultrasound or MRI and biopsy of all enlarged or 
abnormal appearing lymph nodes within 42 days prior to study entry 
• 
Clip placed within the biopsy proven breast cancer, with verification of 
placement by mammogram 60 days prior to study entry 
3.1.6 Patients must have had estrogen and progesterone receptor analysis performed 
on the biopsy specimen prior to study entry according to current ASCO/CAP Guideline 
Recommendations for hormone receptor testing. Testing for her2 neu expression must 
also be performed and recorded prior to study entry. 
3.1.7 CBC/differential obtained within 60 days prior to study entry, with adequate bone 
marrow function defined as follows: 
• 
Absolute neutrophil count ≥1,800 cells/mm3 
• 
Platelets ≥ 75,000 cells/mm3 
• 
Hemoglobin ≥8.0g/dl.   
3.1.8 Women of childbearing potential must be non-pregnant and non-lactating and 
willing to use medically acceptable forms of contraception during radiation therapy 
3.1.9 Patient must provide study specific informed consent prior to study entry 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 12 of 39 
 
3.1.10 Prior breast augmentation, including breast implants, is allowed 
3.1.11 Patients with a prior history of contralateral breast cancer will be considered 
eligible if they completed all treatment (including anti-endocrine therapy) more than 2 
years prior to registration 
3.1.12 Patients must not have a prior treatment of malignancy diagnosed or treated within 
the past two years, with the exception of non-melanomatous skin cancer, carcinoma in 
situ of the cervix and contralateral breast cancer as described in 3.1.11. 
3.1.13 Interested patients must meet with a medical oncologist prior to study entry to 
determine if a genomic profiling tests (such as Oncotype or Mammaprint) is 
recommended. If recommended and patient is amenable to the possibility of receiving 
chemotherapy, there must be adequate biopsy tissue for testing. If adequate tissue is not 
available for the testing, patients who are very interested in participation may undergo 
additional biopsies. If a patient plans to refuse chemotherapy regardless of a high profiling 
results and elects to forgo the test, they will still be eligible for enrollment.  
 
3.2 
Conditions for Patient Ineligibility 
 
3.2.1 AJCC clinical T3, N1-3, M1, stage IIB, stage III or stage IV breast cancer 
 
3.2.2 Prior invasive non-breast malignancy (exceptions include non-melanomatous skin 
cancer, carcinoma in situ of the cervix, or prior contralateral breast cancer as described in 
3.1.11) unless disease free and off treatment for a minimum of 5 years prior to study entry. 
 
3.2.3 Multifocal breast cancer 
 
 
 
3.2.4 Estrogen receptor negative disease 
 
3.2.5 Lymphovascular space invasion noted on biopsy 
 
3.2.6 Invasive lobular carcinoma 
 
3.2.7 Purely non-invasive breast cancer (i.e. ductal carcinoma in situ (DCIS), lobular 
carcinoma in situ). Note: DCIS is often associated with invasive ductal carcinoma. 
Associated DCIS does NOT preclude eligibility as long as there is invasive carcinoma on 
the biopsy specimen. 
 
3.2.8 Non-epithelial breast malignancies such as sarcoma or lymphoma 
 
3.2.9 Paget’s disease of the nipple 
 
3.2.10  Male breast cancer 
 
3.2.11 Prior history of radiation therapy to the chest in the region of the ipsilateral breast 
that would result in overlap of radiation fields. 
 
3.2.12 Patients having received or having planned neoadjuvant chemotherapy or 
concurrent chemotherapy. A recommendation for adjuvant chemotherapy will not preclude 
eligibility. However, if a patient has an Oncotype score that would lead to a 
recommendation for systemic chemotherapy (see section 3.1.13), and chemotherapy is 
planned to be given in the neoadjuvant setting, the patient would then be ineligible for 
enrollment. 
 
3.2.13 Patients who are unable to undergo MRI. This could include patients with a severe 
allergy to gadolinium contrast or patients with renal function insufficient to receive contrast 
(GFR less than 30). Patients who have a minor allergy (for example, skin rash or hives) to 
gadolinium contrast may still be considered for enrollment. These patients would have to 
receive prophylactic prednisone and diphenhydramine per MCW department of radiology 
protocol. Such cases should be reviewed with the principal investigator and radiology co-
chair prior to enrollment. 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 13 of 39 
 
 
3.2.14 History of connective tissue disorder, including lupus, dermatomyositis and 
scleroderma 
 
 
3.2.15  Known BRCA mutation 
 
3.2.16 Severe, active co-morbidity, defined as follows: 
• 
Unstable angina and/or congestive heart failure requiring hospitalization 
within the last 6 months 
• 
Transmural myocardial infarction within the last 6 months 
• 
Acute bacterial or fungal infection requiring intravenous antibiotics at the 
time of registration; 
• 
Chronic Obstructive Pulmonary Disease exacerbation or other respiratory 
illness requiring hospitalization or precluding study therapy within 30 days 
before registration; 
• 
Hepatic insufficiency resulting in clinical jaundice and/or coagulation 
defects; note, however, that laboratory tests for liver function and 
coagulation parameters are not required for entry into this protocol 
• 
Acquired Immune Deficiency Syndrome (AIDS) based upon current CDC 
definition; note, however, that HIV testing is not required for entry into this 
protocol. The need to exclude patients with AIDS from this protocol is 
necessary because the treatments involved in this protocol may be 
significantly immunosuppressive 
3.2.17 Medical, psychiatric or other condition that would prevent the patient from receiving 
the protocol therapy or providing informed consent 
3.2.18 Patients, who under the best estimates of the treating radiation oncologist, have a 
life expectancy of 10 years or less 
3.2.19  Patients who are pregnant 
 
4.0       Pre- and Post-Treatment Evaluation and Management 
Note: This section lists baseline evaluations needed before the initiation of protocol 
treatment that do not affect eligibility. For specific studies that affect eligibility, please 
see section 3.0. 
 
4.1 Required Pre-Treatment Evaluations/Management 
4.1.1 Patients must complete forms and have photos taken for cosmetic evaluation on 
the study 
4.1.2 Bone scan or any other staging work-up for patients when warranted based on 
symptoms or at the discretion of the treating physicians should be completed prior 
to enrollment. Similarly, work up of abnormal labs or physical exam findings should 
all be completed prior to enrollment.  
 
4.2 Required Post-Treatment Evaluations/Management 
4.2.1 Patients will be seen one month after radiation treatment and evaluated for acute 
side effects of treatment. Breast exam from this visit will be documented. 
4.2.2 A post-radiation MRI scan will be obtained no sooner than 28 days after completion 
of radiation therapy. This scan must be obtained prior to surgery. 
4.2.3 Advanced MRI imaging sequences performed for simulation will be obtained on 
the post-treatment scan. These are described in more detail in section 6.1.9 below. 
4.2.4 Tumor response will be assessed using the RECIST and mRECIST criteria (64).  
Also, changes in the MRI sequences detailed in section 6.1.9 will also be 
assessed. The baseline measurements for this analysis will be taken from the MR 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 14 of 39 
 
sim and not from any diagnostic MRI the patient may have had prior to radiation 
planning. 
4.2.5 Blood draw for future studies of immune markers (see section 9.1.3). These will be 
done prior to radiation treatment, at the end of radiation (+/- 1 treatment) and then 
one month after radiation treatment but prior to surgery. 
5.0      Registration Procedures 
 
5.1 Registration and Monitoring of Patients 
5.1.1 Patients will be screened for eligibility and registered by a Clinical Research 
Associate/Clinical Research Coordinator (CRC/CRA) in the Clinical Trials Office of 
the Froedtert and Medical College of Wisconsin Cancer Center. 
5.1.2 Patients will be registered in the institutional OnCore web-based system under the 
CRA console. 
5.1.3 Registration of patients with consenting, eligibility review, on-study status, 
treatment status, and follow-up will monitored using the OnCore calendar system. 
5.1.4 Serious adverse events (SAEs) and protocol deviations will be reported through 
the OnCore reporting system. 
5.1.5 Questions regarding OnCore systems and data reporting should be reported to 
OnCore data management. 
 
5.2 Questions Regarding Patient Eligibility 
5.2.1 Questions regarding patient eligibility and registration procedures should be 
directed to the principal investigator, Adam Currey, M.D. (acurrey@mcw.edu, 
pager (414) 557-2221, office (414) 805-4462).  
 
5.3 Subject Withdrawal 
5.3.1 Given the short nature of the treatment regimen (radiation is given over 1.5-2 
weeks), and very low rates of toxicity during radiation treatment, it is unlikely that 
patients will withdraw from the study once radiation treatment has begun. 
However, subjects have the right to withdraw from the study at any time.  
5.3.2 Subjects may be withdrawn from the study if a subjects status declines and in the 
opinion of the treating physicians it is in the subject’s best interest to be withdrawn. 
Subjects may also be withdrawn if there is a violation of the protocol inclusion and 
exclusion criteria as deemed relevant by the treating physician and the principal 
investigator.  
5.3.3 It is anticipated that the most likely reason for a subject withdrawal will be for those 
not suitable for APBI based on radiation treatment planning (see Section 6.4 and 
6.4.2 below for further details). As these patients would be withdrawn prior to 
delivery of study related treatment, they will then be replaced on the study and not 
counted toward the total accrual goal of 40 patients. Similarly, patients withdrawing 
for any other reason prior to delivery of treatment will be replaced on the study and 
not counted toward the total accrual goal. 
5.3.4 In the rare case that a patient withdraws from the protocol after the initiation of 
treatment, only data collected up until the date of withdrawal will be used in 
analysis. If the withdrawal occurs during radiation therapy, data will only be 
included in analysis of the primary study endpoint if a post-operative complication 
occurs. 
5.3.5 Patients who withdraw from the study should be treated in accordance with normal 
standards of care. Follow-up will be per the discretion of the patient’s treating 
physicians, but at a minimum be in accordance with NCCN guidelines. 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 15 of 39 
 
Management of disease recurrence or any unforeseen late morbidity of treatment 
will be managed by the treating physicians. 
 
6.0 Radiation Therapy 
 
6.1 Localization, Simulation and Immobilization 
6.1.1 Treatment in the prone position is preferred. Treatment in the supine position will 
be allowed if the patient cannot tolerate that position, or the breast size is not 
suitable for prone RT as determined by the treating radiation oncologist.  
6.1.2 Patients should be optimally positioned with alpha cradle casts and breast boards. 
Note that all immobilization devices must be MRI compatible 
6.1.3 Methods to minimize cardiac exposure and target volume motion such as gating 
and deep-inspiration breath hold are allowed 
6.1.4 A treatment planning CT scan in the treatment position will be required to define 
target volumes and for beam modeling. Dual-Energy CT will also be performed to 
enhance target delineation.  
6.1.4.1 Radio-opaque markers may be placed on external landmarks at the 
acquisition of the CT scan to facilitate contouring segmentation of the CT 
data-set. 
6.1.4.2 The CT should extend cephalad to the mandible and extend sufficiently 
caudally to encompass the entirety of the breast tissue and the lung 
volume.  
6.1.4.3 A CT scan image thickness of 5mm or less should be used 
6.1.5 External skin localization marks which may include permanent tattoos are 
recommended for daily localization and set-up accuracy. 
6.1.6 MRI simulation will also be performed in the treatment position and same 
immobilization device created during the CT simulation.  
6.1.7 MRI simulation will be performed on the 3.0T large bore MRI unit (MAGNETOM 
Verio, Siemens) with gadolinium contrast per Froedtert Hospital guidelines and 
guidelines in the department of radiation oncology. 
6.1.8 Patients will be scanned with commercially available and custom built RF 
transmitter/receiver coils.  
6.1.9 In addition to the standard imaging MR sequences, additional advanced imaging 
sequences will be obtained: 
6.1.9.1 Diffusion Weighted Imaging (DWI) and Apparent Diffusion Coefficient 
(ADC) Map. A DWI sequence of about four minutes duration will be 
acquired. Sequences will be acquired during free-breathing. For patients 
scanned in the prone position, these scans will not be gated (it is 
anticipated that this will be the majority of patients). For patients scanned 
in the supine positon, free breathing will again be used, but the images will 
be gated. B-values of 0-10000 in 6-25 directions will be used in these 
scans. B-values of 50, 400 and 800 will be used to derive the ADC map.   
6.1.9.2 Perfusion Weighted Imaging (PWI) Dynamic Contrast-Enhanced (DCE) will be 
used for perfusion imaging. A spoiled gradient echo sequence will be executed in 
repetition for about eight minutes while a contrast agent is administered 
intravenously to the patient. An FDA approved adult dose (0.05 mmol/kg) of MRI 
gadolinium contrast agent will be used. This contrast agent injection will be used 
to define the macroscopic boundaries of the tumor for T1-weighted post-contrast 
images, which are the standard of care. The acquisition of PWI scans will not 
necessitate any additional amount of contrast agent injection to the patient, 
because both the standard T1-weighted post-contrast images and the PWI images 
will be acquired with the same amount of contrast injection. In case the patient will 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 16 of 39 
 
not be administered contrast agent for the T1-weighted images, as part of the 
standard simulation, then PWI scans will not be performed for that patient.   
 
 
6.2 Treatment Planning – Target Volumes and Organs at Risk 
6.2.1 The definitions for the CTV, PTV and normal structures used in this protocol 
generally conform to the RTOG-endorsed consensus guidelines for delineation of 
target and normal structures for breast cancer. 
(http://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx) 
6.2.2 The target volume will be defined by fusing image data sets in the planning system 
from both CT and MRI scans obtained in the treatment position. Fusion will be 
performed with preference given to breast alignment. 
6.2.3 Target Volumes 
6.2.3.1 Gross Tumor Volume (GTV) will be defined as all gross tumor extent as 
seen on the MRI scan.  
6.2.3.2 Clinical Target Volume 1 (CTV1) will be defined as a 0.5cm expansion 
around the GTV, limited to 5mm within the skin surface and to normal 
barriers to tumor spread such as the muscle and bone of the chest wall. 
This volume is designed to correspond to the tissue that would be removed 
during a typical lumpectomy. 
6.2.3.3 Clinical Target Volume 2 (CTV2) will be defined as a 1.0cm expansion 
around CTV1, again limited to 5mm within the skin surface and to normal 
barriers to tumor spread such as the muscle and bone of the chest wall.  
This volume is similar to the lumpectomy to CTV expansion used in most 
post-operative 
APBI 
protocols. 
This 
total 
expansion 
of 
1.5cm 
(CTV1+CTV2) also correlates with data linking MRI delineation of tumor 
volume with pathological extent of disease (103). 
6.2.3.4 Planning Target Volume (PTV) will be an expansion to account for daily 
set-up uncertainty and motion occurring during treatment. If daily 
kilovoltage CT imaging is used for image guidance treatment delivery, a 
PTV expansion of 0.3 cm will be used. A PTV of 0.5 cm will be used if daily 
megavoltage CT imaging is used.  The PTV should not be limited inside 
the skin or at the chest wall.  This volume will be used for aperture 
generation, but not for analysis of the dose volume histogram. 
6.2.3.5 Planning Target Volume Eval (PTV_Eval) will be based on the PTV, but 
limited to 0.5cm within the skin. It may extend in to the muscle of the 
chestwall, but should not extend deep/posteriorly to the anterior surface of 
the ribs. 
 
6.2.4 Normal Structures 
6.2.4.1 Breast volume – Includes the apparent glandular breast tissue as defined 
on CT and MRI. Consensus anatomical borders as defined in the RTOG 
atlas should be used.  The breast is limited anteriorly within 0.5cm from the 
skin and posteriorly to the anterior surface of the pectoralis and serratous 
anterior muscles and should exclude the chest wall.  
6.2.4.2 Contralateral Breast – Includes the apparent glandular breast tissue as 
defined on CT and MRI. Given the fusion alignment based on the ipsilateral 
breast, MRI data may be less useful in defining this volume. Otherwise, the 
contralateral breast will be defined similarly to the ipsilateral breast as 
described above. 
6.2.4.3 Ipsilateral Lung – may be contoured with auto-segmentation with manual 
verification 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 17 of 39 
 
6.2.4.4 Contralateral Lung – may be contoured with auto-segmentation with 
manual verification 
6.2.4.5 Heart – This is to be contoured in all cases, not just left sided cases. The 
heart should be contoured beginning just inferior to the level in which the 
pulmonary trunk branches into the left and right pulmonary arteries (PA). 
Above the PA, none of the heart’s 4 chambers are present and no contours 
should appear above that level. The heart should be contoured inferiorly 
on every slice inferior to that until its inferior extent near the diaphragm. It 
is not necessary to include pericardial fat in the heart contour.  
6.2.4.6 Thyroid – all lobes of the thyroid should be contoured 
 
6.3 Treatment Planning – Plan Generation 
6.3.1 3D conformal radiation therapy (3DCRT) or intensity modulated radiation therapy 
(IMRT) will be allowed. If 3D planning is used, dose will be delivered through at 
least 3 beams. 
6.3.2 The PTV (not PTV_Eval) will be used for aperture generation 
6.3.3 The dose prescription will be consistent with recently reported phase III study of 
APBI delivered in the post-operative setting. Patients will receive 30Gy in 5 
fractions of 6Gy, given on non-consecutive days (95).  Total treatment duration  
should be no longer than 18 days. 
6.3.4 Skin bolus is not allowed 
 
6.4 Treatment Planning – Dose Constraints 
6.4.1 PTV 
6.4.1.1 Ideal – 95% of the PTV will be covered by the prescription dose of 30Gy 
Acceptable Variation – 95% of the PTV will be covered by 95% of the 
prescription dose 
6.4.2 Breast Volume 
6.4.2.1 Ideal – Less than 25% of the total breast volume should receive the 
prescription dose of 30Gy 
Acceptable Variation – Less than 35% of the total breast volume should 
receive the prescription dose of 30Gy 
6.4.2.2 Ideal – Less than 45% of the total breast volume should receive 50% of the 
prescription dose (15Gy) 
Acceptable Variation – Less than 50% of the total breast volume should 
receive 50% of the prescription dose (15Gy) 
 
Note: Failure to meet the above constraints may constitute a patient who is not a 
candidate for APBI. If both these constraints are not met, the patient should be 
taken off study and treated per standard of care. 
 
6.4.2.3 Ideal – Max dose within the breast should be less than 108% of the 
prescription dose (32.4Gy) 
Acceptable Variation – Max dose within the breast should be less than 
110% of the prescription dose (33Gy) 
 
6.4.3 Contralateral Breast 
6.4.3.1 Ideal – Less than 5% of the contralateral breast should receive 5% of the 
prescription dose (1.5Gy). 
Acceptable Variation – Less than 5% of contralateral breast should receive 
8% of the prescription dose (2.4Gy). 
 
6.4.4 Ipsilateral Lung 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 18 of 39 
 
6.4.4.1 Ideal – Less than 10% of the ipsilateral lung should receive 30% of the 
prescription dose (9Gy). 
Acceptable Variation – Less than 15% of the ipsilateral lung should receive 
30% of the prescription dose (9Gy). 
6.4.4.2 Ideal – Less than 30% of the ipsilateral lung should receive 10% of the 
prescription dose (3Gy). 
Acceptable Variation – Less than 35% of the ipsilateral lung should receive 
10% of the prescription dose (3Gy). 
 
6.4.5 Contralateral Lung 
6.4.5.1 Ideal – Less than 10% of the contralateral lung should receive 10% of the 
prescription dose (3Gy). 
Acceptable Variation – Less than 15% of the contralateral lung should 
receive 10% of the prescription dose (3Gy). 
 
6.4.6 Heart 
6.4.6.1 For Left Sided Cases: Ideal – Less than 10% of heart should receive 5% of 
the prescription dose (1.5Gy). 
Acceptable Variation – Less than 10% of the heart should receive 8% of 
the prescription dose (2.4Gy). 
Ideal – Mean heart dose should not exceed 200cGy 
Acceptable Variation – Mean heart dose should not exceed 320cGy 
 
6.4.6.2 For Right Sided Cases: Ideal – Less than 5% of heart should receive 5% 
of the prescription dose (1.5Gy). 
Acceptable Variation – Less than 5% of the heart should receive 8% of the 
prescription dose (2.4Gy). 
Ideal – Mean heart dose should not exceed 200cGy 
Acceptable Variation – Mean heart dose should not exceed 320cGy 
 
6.5 Radiation Treatment Delivery 
6.5.1 Treatment should generally begin within 60 days of enrollment. At least one day 
will elapse between each fraction so that treatments are not delivered on 
consecutive days. 
6.5.2 A pair of orthogonal portal images will be obtained at time of the second simulation 
and will be reviewed by a radiation oncologist prior to the first treatment. 
6.5.3 Daily CT or MRI-based image guided radiotherapy will be used for table shifts and 
field placement at the time of second simulation and with each treatment fraction. 
Alignment to the biopsy clip, breast position, and tumor if visible on CT/MRI will be 
used. 
6.5.4 On-line adaptive replanning will be allowed for patients treated with daily 
kilovoltage-CT or MRI based image guided radiotherapy. 
6.5.5 Treatment should ideally be given over no more than 14 elapsed days, but up to 
18 days will be allowed. Extenuating circumstances (e.g. patient unable to come 
for treatment, prolonged down-time on treatment machine) resulting in treatment 
interruption will be clearly documented. 
6.5.6 Patients will be seen once during the treatment course for weekly review as per 
standard protocols in the radiation oncology department. Ideally, one of those visits 
should occur on the last day of treatment. Breast exam during that visit and 
documentation of skin reactions will be documented. 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 19 of 39 
 
7.0       Systemic Therapy 
 
7.1 Chemotherapy 
Chemotherapy may be given and chemotherapeutic agents used are at the discretion of the 
patient’s medical oncologist. The use of chemotherapeutic agents before or during radiation 
therapy is not allowed and is permitted only as an adjuvant to surgery as is the current standard 
for patients treated with post-operative APBI.  
For the patient population for this study, resected tumor specimens often are tested with a 
commercially available quantitative reverse transcriptase polymerase chain reaction (RT-PCR) 
analysis of 21 individual genes. The results of this assay are then used to develop a recurrence 
score to guide decisions regarding systemic chemotherapy (OncotypeDx). Because this test is 
usually performed on the final surgical specimen, there is concern that any tumor regression 
occurring as a result of pre-operative radiation therapy might lead to a loss of important 
information that can guide treatment decisions. However, if there is adequate tumor present in 
the core biopsy used to diagnose breast cancer, the 21-gene assay may be performed on the 
biopsy specimen instead of the final surgical specimen. Furthermore, data presented at the San 
Antonio Breast Cancer Symposium in 2011 demonstrated 92% concordance between Oncotype 
performed on core biopsies and surgical specimens (93). This level of concordance is comparable 
to that of negative sentinel lymph node biopsy predicting no axillary lymph node involvement. In 
a recent analysis of the 548 reportable Oncotype DX tests performed at Froedtert Hospital from 
2010-mid 2015, only 9% had a high recurrence score (Data from Oncotype reporting, prepared 
by Denise Keeler). Furthermore, the patients on this protocol are generally considered low risk 
for a high Oncotype Score.   
Included in the eligibility criteria for this protocol is that the biopsy specimen contain adequate 
tissue to perform the OncotypeDx assay. The high concordance of biopsy OncotypeDx score with 
final surgical specimens coupled with the very low probability of a high Oncotype recurrence score 
in this patient population make it extremely unlikely that a patient with a high score will somehow 
be missed and hence not receive systemic chemotherapy as a result of receiving pre-operative 
radiation therapy. 
7.2 Hormonal Therapy 
As patients are required to have ER positive disease, all patients should be treated with anti-
endocrine therapy per current guidelines. Treatment should be given at a minimum of 5 years 
post-surgery. The choice of anti-endocrine agent is at the discretion of the patient’s medical 
oncologist, and dose and schedule should be consistent with the instructions in the drug package 
inserts. Hormone therapy cannot be initiated until after surgery. While patients should be strongly 
encouraged to complete a minimum of 5 years of anti-endocrine therapy, failure to do so for 
whatever reason will not result in a protocol deviation or be the cause of study withdrawal. 
7.3 Trastuzumab 
Trastuzumab or other anti-HER2 agents are permitted at the discretions of the patient’s medical 
oncologist for patients whose tumors are HER2 positive. The dose and schedule of these agents 
should be per standard treatment protocol, but cannot be given until after surgery. 
 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 20 of 39 
 
8.0       Surgery and Post-Operative Treatment 
8.1  Breast conserving surgery  
Breast conserving surgery (lumpectomy) and sentinel node biopsy will occur no sooner than 5 
weeks following completion of RT, but should occur no later than 8 weeks. In patients with rectal 
cancer, this interval has been shown to produce optimal response to pre-operative radiation 
while maintaining low rates of post-operative complications (101). Surgical techniques such as 
needle localization will be performed at the discretion of the treating surgeon and in 
concordance with current standard of care. Oncoplastic procedures are discouraged, but will 
not be counted as a protocol violation or removal from the study. 
8.2  Sentinel lymph node biopsy and management of the axilla 
Sentinel lymph node biopsy should be performed at the time of lumpectomy. But at the discretion 
of the treating physicians, it may be performed prior to the initiation of radiation therapy. Dual 
tracer with radiocolloid together with blue dye is required. If a sentinel lymph node is positive for 
metastatic disease with any focus >0.2 mm (i.e. stage N1mic or higher), axillary node dissection 
may be performed at the discretion of the treating physicians. In the unlikely event that there 
are 4 or more positive lymph nodes, patients will require RT to the regional lymph nodes. Given 
the patient selection criteria and pre-treatment evaluation, this scenario would be extremely 
unlikely. 
8.3  Management of a positive margin 
The need for surgical re-excision after the initial lumpectomy because of close or positive 
margins will be determined by the treating surgeon and radiation oncologist. For any patient 
with a positive margin, re-excision is required unless technically not possible (i.e. poor 
anesthesia risk for the patient, inability to resect additional breast tissue at the site of the positive 
margin). 
8.4  Post-operative Radiation Therapy 
It is conceivable that patients deemed appropriate for APBI and are study eligible may have 
findings on final pathology that would make them inappropriate candidates for APBI. Careful 
selection criteria for this study make this scenario very unlikely. However, if a patient has a 
nodal metastasis >2mm (N1 or higher), post-operative whole breast irradiation should be 
strongly considered.  Similarly, whole breast irradiation should also be considered for patients 
with persistently positive resection margins and then refuse mastectomy or with an extensive 
intraductal component. Regional nodal irradiation will be added to the whole breast irradiation 
and required for patients with 4 or more positive nodes, and should be considered for those with 
1-3 positive nodes. Dose and fractionation of the subsequent treatment will be left to the 
discretion of the treating radiation oncologist. A boost to the surgical bed in the breast should 
be discouraged. 
This approach is patterned after that used on the TARGIT-A trial. In that study, intra-operative 
APBI was administered to patients before the final results of surgical pathology were available. 
Patients who were found to have high risk features and not deemed appropriate for APBI alone 
after final pathology received whole breast irradiation without significant adverse effect (96).  
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 21 of 39 
 
9.0        Pathologic Evaluation and Genetic Evaluation of Tissue Specimens 
 
9.1 Pathological Evaluation and Immune Biomarkers 
9.1.1 The surgical specimens will be subject to routine pathological analysis. Remaining 
tissue from the pre-treatment biopsy, as well as any residual tumor tissue post-RT, 
will be stored in accordance with MCW department of Pathology guidelines. 
Routine hematoxyline and eosin (H&E) stain will be used for morphological analysis 
and for the determination of immune cell infiltrates. The samples will be assessed 
by the breast pathologist as previously described (65,66). One H&E slide and 20 
unstained slides will be reserved for Gene Expression Profiling (described in section 
9.2 below).  
9.1.2 Immune cell infiltrates have previously been shown to correlate with both breast 
cancer-specific outcomes and response to neoadjuvant treatment (67). We 
anticipate that enhanced immune cell infiltration (determined as described above in 
8.1.1, or with additional immunostains if needed and tissue available allows) will 
correlate with pathologic responses to RT.  
9.1.3 Blood specimens (50mL, collected in 10mL lavender top EDTA tubes) will be 
obtained at the time of routine blood draws: once pre- and once post-radiation, (last 
day and up to one week after +/- 1 treatment) for future studies of immune 
markers/peripheral blood cells and other cancer and treatment related biomarkers 
that will attempt to predict radiation side effects and potentially treatment 
responses. These samples will be obtained at Froedtert Hospital, and in order to 
spare patient additional travel, those receiving radiation treatment outside 
Froedtert may opt out of the blood draw at the end of radiation. These samples will 
also be stored on the MCW Campus and analysis will be performed on campus. 
The process for handling specimens will be as follows: 
9.1.3.1 After collection, invert tube(s) multiple times to ensure adequate 
mixing of EDTA. *Call the co-PI’s laboratory (Dr. Bergom) at 414-
955-8629 to let them know they need to come pick up the 
PBMCs. If no answer, call the co-PI at 262-510-6488. The 
plasma will be processed in the laboratory performing the 
blood draw, and the PBMCs will be collected by the PI’s 
laboratory member for the remainder of the processing 
outlined below. 
9.1.3.2 Performed 
by 
the 
blood 
draw 
laboratory: 
Centrifuge 
specimen(s) within one hour of collection in a standard clinical 
centrifuge at ~2500 RPM for 10 minutes at 4°C (preferred). If unable 
to process the samples at 4°C then spinning at room temperature 
is acceptable if done within 2 hours of draw. If the interval between 
specimen collection and processing is anticipated to be more than 
one hour, keep specimen on ice until centrifuging is performed.  
9.1.3.3 Performed by the blood draw laboratory: Carefully pipette and 
aliquot 0.5mL plasma into 8 cryovials labeled with case numbers, 
collection date/time, time point collected and clearly mark specimen 
as “plasma”. Avoid pipetting up the buffy coat layer.  
9.1.3.4 Place cryovials into biohazard bag and immediately freeze at -70 to 
-90°C.  
9.1.3.5 Store frozen plasma until ready for analysis 
9.1.3.6 Performed by the PI’s laboratory: PBMCs should be separated 
using sterile and endotoxin free Ficoll density gradient 
solution.  The peripheral blood mononuclear cells (PBMCs) should 
be removed and pooled. The PBMC layer should be resuspended 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 22 of 39 
 
in three times the volume of cold sterile PBS. Cells should be 
counted using a hemocytometer and the total cell number should 
be noted. The expected yield is 1-2 million cells per ml of blood.   
9.1.3.7 Performed by the PI’s laboratory: The PBMCs collected from 3 
lavender top tubes will be divided into three aliquots. Roughly two-
thirds of the cells should be cryopreserved for future analysis (see 
next item). Roughly one-third of the cells will be placed in RNAlater 
(see instructions below) and snap frozen with liquid nitrogen and 
stored at -70 to -80°C for future RNA extraction. If there are more 
than 15E6 viable cells the RNA later aliquot should be limited to a 
total of 5E6 cells and the additional cells should be cryopreserved 
at -70 to -90 °C, thus deviating from the 2:1 aliquoting. 
9.1.3.8 Performed by the PI’s laboratory: Cryopreservation; After 
counting, PBS washed PBMCs should be divided into aliquots of 5 
million cells and spun down at approximately 1,000-1,500 rpm (400 
x g) for 10 minutes. Each aliquot should be resuspended in 1ml of 
cold sterile CryoStor CS10 freeze media (catalog number 07930, 
STEMCELL technologies) which contains 10% DMSO. Each 1ml 
aliquot should be placed in a cryopreservation tube and the lid 
should be tightly secured. Tubes should be placed into a "Mr. 
Frosty" or other slow freeze container and placed into a -70 to -80°C 
freezer for 12-24 hours. Tubes should then be transferred to and 
stored in vapor phase liquid nitrogen (-135°C) until analyzed in 
batches.  
9.1.3.9 Performed by the PI’s laboratory: RNA later: After counting, PBS 
washed PBMCs should be spun down at approximately 1,000-
1,500 rpm (400 x g) for 10 minutes. The cell pellet should be re-
suspended in 1ml of RNAlater solution snap frozen in liquid nitrogen 
and stored at  -70 to -80°C until analyzed in a batched manner. 
9.1.4 Peripheral Blood Analysis 
9.1.4.1 Plasma: Plasma samples will be stored at Dr. Bergom’s Laboratory 
for batched analysis. Plasma will be interrogated for chemokine and 
cytokine levels using a multiplex platform from Eve Technologies 
(https://www.evetechnologies.com).  
9.1.4.2  Cryopreserved samples: Cryopreserved samples will be stored Dr. 
Bergom’s Laboratory for batched analysis. Samples will be thawed 
and stained with fluorophore-conjugated antibodies against one or 
more of the following: CD4, CD8, CD25, CD62L, CD45RA, CD127, 
ICOS, PD-1, PD-L1, FoxP3, CD3, CD56, CD16, CD83, TIM-3, Ki-
67, CD19, CD20, CD33, CD15, CD11b, HLA-DR  and others. 
Stained cells will be interrogated by flow cytometry and results 
analyzed using FlowJo or similar software.  
9.1.4.3 RNAlater samples: Cells in RNA later will be stored Dr. Bergom’s 
Laboratory for batched analysis. Samples will be thawed and RNA 
will be extracted. The transcriptome will be analyzed by RNA deep 
sequencing (RNAseq) using the Illumina HiSeq platform. Targeted 
RT-PCR will be used to validate genes of interest identified by 
RNAseq. TCR deep sequencing data may also be obtained from 
the RNAseq. 
 
9.1.5 The evaluating pathologist will assess the percentage of the surgical specimen that 
contains live tumor.  

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 23 of 39 
 
9.1.6 Sections will be subject to immunohistochemical evaluation of the marker Ki-67 
pre- and post-operatively to estimate the tumor cell population capable of 
proliferation after treatment (68). Since the monoclonal antibody Ki-67 detects a 
nuclear antigen expressed in all phases of the cell cycle except G0, this offers a 
unique means to assess response to radiotherapy. This approach has never 
before possible with standard breast radiation treatment, because standardly 
treatment is delivered after all measurable tumor has been removed. 
 
 
 
9.2 Gene Expression Profiling and Advanced Imaging:  
9.2.1 RNA will be procured using the Tissue Bank quality control measures fixed paraffin 
embedded tissues pre-radiation (from biopsy) and post-radiation (surgical 
specimen). 
9.2.2 We will perform global gene expression profiling using RNAseq to identify 
differential expression patterns that correlate with response to radiation. We will 
utilize the MCW Human and Molecular Genetics Center Sequencing Core to 
perform RNAseq and analysis. Total RNA will be extracted using Trizol per the 
MCW Tissue Bank’s standard procedure, and the total RNA will be poly-A purified, 
transcribed, and chemically fragmented using Illumina’s TruSeq RNA library kit. 
Libraries will be prepared for each sample, indexed for multiplexing, and then 
sequenced on an Illumina HiSeq 2000. Briefly, we will plan to multiplex 4 libraries 
per lane x 8 lanes per flow cell, enabling us to test 32 samples per flowcell, a setup 
which has routinely yielded us 150-180 million reads (87.5% mapped reads) per 
lane. For data analysis, sequencing reads will be demultiplexed and compressed 
into FASTQ files using CASAVA 1.8 or equivalent software, aligned to the human 
genome by TopHat (69), and analyzed for transcript abundance using Cufflinks 
(70). Cufflinks produces FPKM (fragments per Kb of exon per million fragments 
mapped) values for all transcript isoforms. The CuffDiff2 program (part of Cufflinks 
package) then statistically analyzes differences in transcript abundance, taking 
into account variance between biological replicates and correction for false 
discovery rate (71). 
9.2.3 Expression of genes from patients with pathologic complete response versus 
non-complete responders will be compared using an unpaired t test on all 
probes, with a false-discovery rate (FDR) of less than 0.05. If <15% complete 
pathologic responses are seen, then partial responses versus no response will 
be compared.  
9.2.4 Expression of genes from patients with pre- and post-radiation will be compared, 
with a false-discovery rate (FDR) of less than 0.05.  
9.2.5 Gene expression data from this patient group will be compared to previously 
published gene expression signatures for radiation sensitivity, and OncotypeDx, 
a metric that predicts chemotherapy response (79,89,90). 
9.2.6 Correlation of MR parameters and gene expression differences will be 
performed as described previously (90).  Correlation of MRI parameters and CT-
imaging with pathologic responses will also be determined. 
9.2.7 Additional focus will be placed on genes with a statistically significant change in 
expression (with p<0.05).  Pathway analysis will be used to identify likely putative 
genes which modulate radiation response. Targets identified as potentially 
leading to enhanced responsiveness will be used to generate a novel gene 
signature and tested and validated as prognostic factors in future studies. 
 
10.0 
       Patient Assessments 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 24 of 39 
 
 
10.1 
Study Parameters 
10.1.1 See Appendix 1 for a summary of assessments and time frames 
10.1.2 Breast assessments will be conducted during radiation therapy with one ideally 
occurring on the last day of treatment 
10.1.3 A breast exam must be conducted by a Physician, Physician Assistant or Nurse 
Practitioner at clinic visits and documented 42 days prior to study entry, 4-6 weeks 
post radiation, prior to surgery, no later than one month after the last surgery (post-
operative visit), six months after surgery, 12 months after surgery (+/- 2 months) 
and then annually until 5 years after treatment is completed. The annual follow-up 
interval of 12 months +/-2 months will be calculated from the actual date of the last 
follow-up visit. 
10.1.4 Post-operative complications (the primary endpoint of the study) will be defined as 
any complication occurring within 3 months of surgery. These may include but are 
not limited to: post-operative infection requiring oral/IV antibiotics (CTCAE grade 2 
or higher), need for hospital re-admission due to surgical complications, wound 
dehiscence (CTCAE grade 2 or higher), significant hematoma at the operative site 
requiring drainage (CTCAE grade 2 or higher), and persistent symptomatic seroma 
formation that will be defined as need for seroma drainage or need for pain 
medications because of seroma formation (CTCAE grade 2 or 3), or any need for 
re-operation excluding re-excision for concerns related to resection margin. 
10.1.5 At follow-up visits (see Appendix I for schedule), documentation will be made of 
disease status (no evidence of disease, local recurrence, regional recurrence, or 
distant recurrence) and toxicity. Toxicity will be graded according to CTCAE v4.0.  
 
 
10.2 
Cosmetic Outcomes 
10.2.1 Physician reported cosmetic outcome has been consistently reported from 
prospective studies evaluating new methods for breast radiation. It is important to 
document physician reported cosmetic outcomes with this novel treatment method 
as well.  
10.2.2 Physician assessed cosmetic outcome will be assessed prior to radiation, at the 
end of radiation, one month following radiation prior to surgery, one month after 
the last surgery, six months after surgery, 12 months after surgery and then 
annually until 5 years after treatment is completed.   
10.2.3 Cosmetic assessments will be assessed using a 4 point scale. The form contained 
in Appendix III will be used for data collection. 
10.2.4 Digital photographs will be taken of the treated and untreated breasts using an 
RTOG established protocol familiar to the research associates at Froedtert 
Hospital. These images will be taken prior to treatment, one month after surgery, 
then 6 months, 12 months, 24 months and 36 months after surgery. Two digital 
images will be taken at each of these assessment points. One will be a close up 
of the treated breast alone in order to provide detailed information regarding the 
treatment effects. The second digital image will be a straight frontal view of both 
breasts taken in either a standing or seated position with the patient’s hands 
symmetrically placed on her hips. Care will be taken to exclude the face and 
framing and focusing will be done to include both the treated and untreated breast 
to allow optimal comparison for symmetry.  
10.2.5 Photos will then be saved in MCW’s secure I: drive with the following naming 
convention: 
Save photo as: “Case #, View, Time Point” (ex. 7 Single_6mo; or  
12 Both_1) 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 25 of 39 
 
Breast View: Single = Treated breast; Both = Both breasts 
Time Point: B=Baseline prior to radiation; 1mo = 1 month post-
surgery; 6mo = 6months post-surgery; 1 = 1 year post-surgery; 2 = 
2 years post- surgery; 3 = 3 years post-surgery  
10.2.6 The digital images will later be evaluated for cosmetic results by the investigators 
using the criteria established in previous trials (again see Appendix III). It is of 
interest and important to obtain multiple measures of cosmetic outcome. With this 
protocol, three methods will be undertaken – physician reported outcomes 
assessed at time of follow-up, photographs to be evaluated by the investigators, 
and patient reported outcomes as described in the next section. 
 
10.3 
Quality of Life Outcomes and Patient Reported Outcomes 
10.3.1 The Breast Cancer Treatment Outcome Scale (BCTOS) is a 22 item measure of 
perceived aesthetic (e.g. breast shape) and functional status (e.g. pain and 
mobility) that has been used after breast conserving therapy and radiation 
(Appendix IV) 
10.3.2 The BCTOS has high reliability and validity and has been used in a variety of 
previous studies on recovery from breast cancer treatment, including studies of 
post-operative APBI. 
10.3.3 The BCTOS focuses on symptoms that are specifically relevant to radiation 
therapy (e.g. skin problems, breast tenderness, fibrosis) 
10.3.4 These forms will be completed prior to treatment, at the end of treatment, one 
month after radiation, one month after surgery, then 6 months after surgery, then 
12 months, 24 months, 36 months, 48 months and 60 months after surgery or 
chemotherapy (if given), whichever is later. These may be collected +/- 2 months 
from the specified time points. 
10.3.5 The BCTOS will ideally be completed at clinic visits, but may be completed by mail 
or over the phone by research associates. 
10.3.6 As the BCTOS has been used on previous studies of radiation therapy, the data 
collected from this study can then be compared to historical controls of patients 
treated with more traditional post-operative radiation therapy regimens including 
post-operative APBI. 
 
10.4 
Patient Safety Monitoring and Confidentiality 
10.4.1 This study will be reviewed by the Medical College of Wisconsin Cancer Center 
Data and Safety Monitoring Committee (MCWCC DSMC). A summary of the 
MCWCC DSMC activities are as follows: 
10.4.1.1 
Review the clinical trial for data integrity and safety 
10.4.1.2 
Review all unexpected grade 3, and all grade 4, and 5 
adverse events, as well as any others requiring expedited reporting 
as defined in this protocol. (Grades 4 & 5 events must be reported 
to the DSMC within 5 calendar days of study staff’s knowledge.) 
10.4.1.3 
Review all Data and Safety Monitoring reports. 
10.4.1.4 
Submit a summary of any recommendations related to study 
content.  
10.4.1.5 
Terminate the study if deemed unsafe for patients. 
10.4.2 A copy of the MCWCC Data and Safety Monitoring Plan and membership roster 
will be maintained in the study research file and updated as membership changes. 
The committee will review reports from the study PI twice annually (or more 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 26 of 39 
 
frequently if needed) and provide recommendations on trial continuation, 
suspension or termination as necessary. 
10.4.3 Any available DSMC letters will be submitted to the IRB of record as required. 
10.4.4 Data on patient information and follow-up information will be collected and entered 
into the password protected OnCore system. Data will be accessible only by the 
research team and DSMC. 
10.4.5 Hard copy forms (see Appendix III and IV) will be kept in a locked file in offices of 
the CTO. The forms will be linked to patients by a unique identifier and patient 
initials in the event that the identifier is transcribed incorrectly. Access to these 
forms will be limited to the CRA and PI only as the data collected will be entered 
in to OnCore. 
 
11.0 
Statistical Considerations 
11.1 
Sample Size, Power Calculations, and Comparison of Post-Operative Complications to 
Historical Controls 
The primary endpoint of this study will be post-operative complications (as defined in section 
10.1.4). The complication rate measured on this study will be compared to a historical control 
of 32% of patients, as outlined in section 1.6. This will be measured on an individual patient 
level. Hence a surgical complication rate that exceeds 31% will be considered unacceptable 
and result in a negative study. A post-op complication rate of 14% or less will be considered a 
successful demonstration of the safety of this treatment. This number was selected because it 
is roughly half the complication rate observed on the study by Horton et.al. (94) and represents 
an increase in complication rate of only 8% over that reported by Boostrom et.al. (102). To 
demonstrate this, a Simon’s two stage design (104) will be used for this study. The value of this 
approach is that in stage 1 it can be demonstrated that pre-operative APBI using this dose and 
fractionation scheme is not excessively risky. Once that condition is satisfied, stage 2 is then 
used to demonstrate that it meets a better standard of complications compared to the Horton 
study with only a modest increase in complications when compared with historical series of 
complications observed without pre-operative radiation therapy. 
For this analysis we assume as a null hypothesis that the true complication rate is 0.31. This 
will be tested against a one-sided alternative. In stage one of accrual, 17 patients will be 
enrolled. If there are 5 or more complications in these 17 patients, enrollment will be suspended 
and the study will be evaluated for possible closure. This will serve as the stopping rules for the 
study under the null hypothesis of a 31% complication rate. Otherwise, 22 additional patients 
will be accrued (total 39) in stage two, and the null hypothesis will be rejected if there are 7 or 
fewer complications among the 39 total. This design yields a type I error rate of approximately 
0.05 and power of 0.80 when the true complication rate is 14%. With this design, the probability 
of stopping early is 0.6453. To allow for possible withdrawal prior start of treatment or other 
unforeseen problem with enrollment, total enrollment will be 40 patients. 
Sample size for Simon’s Two-Stage Design was calculated using a web-based calculator 
(retrieved February 11, 2016) (106). 
In 2012-2013, 586 new cases of invasive breast cancer were seen at FH. This included 424 
patients who had stage I and IIA disease, the population targeted in this proposal. We estimate 
that 60-70% of these patients would be eligible for screening, with 30-40% eligible for the study. 
This will allow for an adequate pool of patients for the targeted enrollment of 40 patients.  
11.2 
Secondary Endpoints 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 27 of 39 
 
Secondary endpoints of the study will include (1) local control, (2) overall survival, (3) need for 
surgical re-excision due to inadequate margin, (4) Soft tissue fibrosis of the breast, (5) Breast 
pain, (6) radiologic and pathologic response, and (7) cosmetic outcome. The re-excision rate and 
rate of partial/complete response with be estimated with exact confidence intervals, and 
compared to historical controls (28 and 95) using Chi-Square or Fisher’s exact tests. Kaplan-
Meier survival estimates or estimate of the cumulative incidence rate will be used where censoring 
or competing risks occur (local control, cosmetic outcomes, fibrosis, and pain). 
11.3 
Statistical Analysis of Translational Studies 
A description of the statistical methods for the measurement of the changes in gene expression 
is also contained in section 9.2.2 through 9.2.4. Analysis will be performed using the CuffDiff2 
program, part of a commercially available Cufflinks package that will be used in the analysis of 
the tissue samples. The software models how variability in measurements of a RNA transcript’s 
fragment count is dependent on both its expression and splicing structure. It fits the observed 
variance in fragment counts as a function of the mean across replicates. It then estimates the 
number of fragments that originated from each transcript. The algorithm estimates uncertainty by 
calculating the confidence that each fragment is correctly assigned to the transcript that generated 
it. The uncertainty in the fragment’s count is then mapped as a beta distribution and the 
overdispersion in RNA sequences as a negative binomial. The algorithm then mixes the 
distributions together. The result is a beta negative binomial distribution that reflects both the 
sources of variability in an isoform’s measured expression level. This method is well published 
and further detail can be found in reference 71. 
Expression of genes from patients with pre- and post-radiation will be compared, with a false-
discovery rate (FDR) of less than 0.05.  
Expression of genes from patients with pathologic complete response versus non-complete 
responders will be compared using an unpaired t test on all probes, with a false-discovery rate 
(FDR) of less than 0.05. If <15% complete pathologic responses are seen, then partial 
responses versus no response will be compared in a similar manner.  
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 28 of 39 
 
REFERENCES 
1. 
Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial 
comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of 
invasive breast cancer. N Engl J Med 2002; 347(16):1233–1241. 
2. 
Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study 
comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J 
Med 2002; 347(16):1227–1232. 
3. 
Veronesi U, Zucali R, Luini A. Local control and survival in early breast cancer: the Milan 
trial. Int J Radiat Oncol Biol Phys 1986;12(5):717–720. 
4. 
van Dongen JA, Bartelink H, Fentiman IS, et al. Randomized clinical trial to assess the 
value of breast-conserving therapy in stage I and II breast cancer, EORTC 10801 trial. J Natl 
Cancer Inst Monogr 1992 (11):15–18. 
5. 
Blichert-Toft M, Rose C, Andersen JA, et al. Danish randomized trial comparing breast 
conservation therapy with mastectomy: six years of life-table -analysis. Danish Breast Cancer 
Cooperative Group. J Natl Cancer Inst Monogr 1992(11):19–25. 
6. 
Sarrazin D, Le MG, Arriagada R, et al. Ten-year results of a randomized trial comparing a 
conservative treatment to mastectomy in early breast cancer. Radiother Oncol 1989;14(3):177–
184. 
7. 
Poggi MM, Danforth DN, Sciuto LC, et al. Eighteen-year results in the treatment of early 
breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer 
Institute Randomized Trial. Cancer 2003;98(4):697–702. 
8. 
Fisher B, Anderson S, Fisher ER, et al. Significance of ipsilateral breast tumour recurrence 
after lumpectomy. Lancet 1991;338(8763):327–331. 
9. 
Arthur DW, Vicini FA. Accelerated partial breast irradiation as a part of breast conservation 
therapy. J Clin Oncol 2005;23(8):1726–1735. 
10. 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(4):987–1001. 
11. Mukesh M, Harris E, Jena R, Evans P, Coles C. Relationship between irradiated breast 
volume and late normal tissue complications: a systematic review. Radiother Oncol. 2012 
Jul;104(1):1-10. 
12. Vrieling C, Collette L, Fourquet A, et al. The influence of patient, tumor and treatment 
factors on the cosmetic results after breast-conserving therapy in the EORTC “boost vs. no 
boost” trial. EORTC Radiotherapy and Breast Cancer Cooperative Groups. Radiother Oncol 
2000;55(3):219–232. 
13. http://www.rtog.org/CoreLab/ContouringAtlases/BreastCancerAtlas.aspx 
14. Giezen M, Kouwenhoven E, Scholten AN, et al. MRI- versus CT-based volume delineation 
of lumpectomy cavity in supine position in breast-conserving therapy: an exploratory study. Int J 
Radiat Oncol Biol Phys. 2012 Mar 15;82(4):1332-40. 
15. Jacobson G, Zamba G, Betts V, Muruganandham M, Buechler-Price J. Image-Based 
Treatment Planning of the Post-Lumpectomy Breast Utilizing CT and 3TMRI. Int J Breast 
Cancer. 2011 
16. O’Sullivan B, Davis AM, Turcotte R, et al. Preoperative versus postoperative radiotherapy 
in soft-tissue sarcoma of the limbs: a randomised trial. Lancet 2002;359(9325):2235–2241. 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 29 of 39 
 
17. Swedish Rectal Cancer Trial. Improved survival with preoperative radiotherapy in 
resectable rectal cancer. N Engl J Med 1997;336(14):980–987. 
18. van Gijn W, et al. Preoperative radiotherapy combined with total mesorectal excision for 
resectable rectal cancer: 12-year follow-up of the multicentre, randomised controlled TME trial. 
Lancet Oncol 2011;12(6):575– 582. 
19. 
Pisters PW, et al. Rapid-fractionation preoperative chemoradiation, 
pancreaticoduodenectomy, and intraoperative radiation therapy for resectable pancreatic 
adenocarcinoma. J Clin Onc 1998;16(12):3843–3850. 
20. 
Evans DB, et al. Preoperative gemcitabine-based chemoradiation for patients with 
resectable adenocarcinoma of the pancreatic head. J Clin Oncol 2008;26(21):3496–3502. 
21. 
Le Scodan R, et al. Preoperative chemoradiation in potentially resectable pancreatic 
adenocarcinoma: feasibility, treatment effect evaluation and prognostic factors, analysis of the 
SFRO-FFCD 9704 trial and literature review. Ann Oncol 2009;20(8):1387–1396. 
22. 
Albain KS, Rusch VW, Crowley JJ, et al. Concurrent cisplatin/etoposide plus chest 
radiotherapy followed by surgery for stages IIIA (N2) and IIIB non-small-cell lung cancer: mature 
results of Southwest Oncology Group phase II study 8805. J Clin Oncol 1995;13(8):1880–1892. 
23. 
Mohammed ZM, Going JJ, Edwards J, et al. The relationship between components of 
tumour inflammatory cell infiltrate and clinicopathological factors and survival in patients with 
primary operable invasive ductal breast cancer. Br J Cancer 2012;107(5):864-73. 
24. 
Bergom C, Prior P, Kainz K, Morrow NV, Ahunbay EE, Walker A, Li XA, White J. A phase 
I/II study piloting accelerated partial breast irradiation using CT-guided intensity modulated 
radiation therapy in the prone position. Radiotherapy and Oncology, 2013-08-01, Volume 108, 
Issue 2, Pages 215-219 
25. 
Chafe S, Moughan J, McCormick B, et al. Late toxicity and patient self-assessment of 
breast appearance/satisfaction on RTOG 0319: a phase 2 trial of 3-dimensional conformal 
radiation therapy-accelerated partial breast irradiation following lumpectomy for stages I and II 
breast cancer. Int J Radiat Oncol Biol Phys. 2013 Aug 1;86(5):854-9 
26. 
Vicini F, Winter K, Wong J,et al. Initial efficacy results of RTOG 0319: three-dimensional 
conformal radiation therapy (3D-CRT) confined to the region of the lumpectomy cavity for stage 
I/ II breast carcinoma. Int J Radiat Oncol Biol Phys. 2010 Jul 15;77(4):1120-7. 
27. 
Vicini F, Winter K, Straube W, et al. A phase I/II trial to evaluate three--dimensional 
conformal radiation therapy confined to the region of the lumpectomy cavity for stage I/II breast 
carcinoma: initial report of feasibility and reproducibility of Radiation Therapy Oncology Group 
(RTOG) Study 0319. Int J Radiat Oncol Biol Phys 2005;63(5):1531–1537. 
28. 
Olivotto IA, Whelan TJ, Parpia S, et al. Interim cosmetic and toxicity results from RAPID: 
a randomized trial of accelerated partial breast irradiation using three-dimensional conformal 
external beam radiation therapy. J Clin Oncol. 2013 Nov 10;31(32):4038-45. 
29. 
Nichols EM, Feigenberg SJ, Marter K,et al. Preoperative radiation therapy significantly 
increases patient eligibility for accelerated partial breast irradiation using 3D-conformal 
radiotherapy.Am J Clin Oncol. 2013 Jun;36(3):232-8. 
30. 
Nichols EM, Dhople AA, Mohiuddin MM, Flannery TW, Yu CX, Regine WF. Comparative 
analysis of the post-lumpectomy target volume versus the use of pre-lumpectomy tumor volume 
for early-stage breast cancer: implications for the future. Int J Radiat Oncol Biol Phys. 2010 May 
1;77(1):197-202. 
 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 30 of 39 
 
31. 
Polgár C, Van Limbergen E, Pötter R, et al.; GEC-ESTRO breast cancer working group. 
Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: 
recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic 
Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence 
(2009). Radiother Oncol. 2010 Mar;94(3):264-73. 
32. 
Belkacemi Y, Bourgier C, Kramar A, et al. SHARE: a French multicenter phase III trial 
comparing accelerated partial irradiation versus standard or hypofractionated whole breast 
irradiation in breast cancer patients at low risk of local recurrence. Clin Adv Hematol Oncol. 
2013 Feb;11(2):76-83. 
33. 
Vaidya JS, Wenz F, Bulsara M, et al.; TARGIT trialists' group. Risk-adapted targeted 
intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results 
for local control and overall survival from the TARGIT-A randomised trial. Lancet. 2014 Feb 
15;383(9917):603-13. 
34. 
http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=0413 
35. 
van der Leij F, Elkhuizen PH, Janssen TM, et al. Target volume delineation in external 
beam partial breast irradiation: less inter-observer variation with preoperative- compared to 
postoperative delineation. Radiother Oncol. 2014 Mar;110(3):467-70. 
36. 
van Heijst TC, den Hartogh MD, Lagendijk JJ, van den Bongard HJ, van Asselen B. MR-
guided breast radiotherapy: feasibility and magnetic-field impact on skin dose. Phys Med Biol. 
2013 Sep 7;58(17):5917-30 
37. 
Formenti SC, Volm M, Skinner KA, et al. Preoperative twice-weekly paclitaxel with 
concurrent radiation therapy followed by surgery and postoperative doxorubicin-based 
chemotherapy in locally advanced breast cancer: a phase I/II trial. J Clin Oncol. 
2003;21(5):864–870. 
38. 
Adams S, Chakravarthy AB, Donach M,et al. Preoperative concurrent paclitaxel-radiation 
in locally advanced breast cancer: pathologic response correlates with five-year overall survival. 
Breast Cancer Res Treat. 2010 Dec;124(3):723-32. 
39. 
Bollet MA, Belin L, Reyal F, et al. Preoperative radio-chemotherapy in early breast cancer 
patients: Longterm results of a phase II trial. Radiother Oncol. 2012 Jan; 102(1):82-8. 
40. 
McCormick B, Yahalom J, Cox L, et al. The patients perception of her breast following 
radiation and limited surgery. Int J Radiat Oncol Biol Phys 1989;17(6):1299–1302. 
41. 
Darby SC, McGale P, Taylor CW, Peto R. Long-term mortality from heart disease and 
lung cancer after radiotherapy for early breast cancer: prospective cohort study of about 
300,000 women in US SEER cancer registries. Lancet Oncol 2005;6(8):557–565. 
42. 
Darby SC1, Ewertz M, McGale P, et al. Risk of ischemic heart disease in women after 
radiotherapy for breast cancer. N Engl J Med. 2013 Mar 14;368(11):987-98. 
43. 
Rutqvist LE, Liedberg A, Hammar N, et al. Myocardial infarction among women with early-
stage breast cancer treated with conservative surgery and breast irradiation. Int J Rad Oncol Biol 
Phys 1998;40(2):359–363. 
44. 
Fowble B, Hanlon A, Freedman G, et al. Second cancers after conservative surgery and 
radiation for stages I–II breast cancer: identifying a subset of women at increased risk. Int J 
Radiat Oncol Biol Phys 2001;51(3):679–690. 
45. 
Clark RM, Wilkinson RH, Miceli PN, et al. Breast cancer. Experiences with conservation 
therapy. Am J Clin Oncol 1987;10(6):461–468. 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 31 of 39 
 
46. 
Bartelink H, Horiot JC, Poortmans P, et al. Recurrence rates after treatment of breast 
cancer with standard radiotherapy with or without additional radiation. N Engl J Med 
2001;345(19):1378–1387 
47. 
Arthur DW, Cuttino LW, Neuschatz AC, et al. Tumor bed boost omission after negative 
re-excision in breast-conservation treatment. Ann Surg Oncol 2006;13(6):794–801. 
48. 
Romestaing P, Lehingue Y, Carrie C, et al. Role of a 10-Gy boost in the conservative 
treatment of early breast cancer: results of a randomized clinical trial in Lyon, France. J Clin Oncol 
1997;15(3):963–968. 
49. 
Bartelink H, Horiot JC, Poortmans PM, et al. Impact of a higher radiation dose on local 
control and survival in breast-conserving therapy of early breast cancer: 10-year results of the 
randomized boost versus no boost EORTC 22881–10882 trial. J Clin Oncol 2007;25(22):3259–
3265. 
50. 
Fowble B, Solin LJ, Schultz DJ, et al. Breast recurrence following conservative surgery 
and radiation: patterns of failure, prognosis, and pathologic findings from mastectomy 
specimens with implications for treatment. Int J Radiat Oncol Biol Phys 1990;19(4):833–842. 
51. 
Fowble B, Solin LJ, Schultz DJ, et al. Breast recurrence following conservative surgery 
and radiation: patterns of failure, prognosis, and pathologic findings from mastectomy 
specimens with implications for treatment. Int J Radiat Oncol Biol Phys 1990;19(4):833–842 
52. 
Fisher ER, Sass R, Fisher B, et al. Pathologic findings from the National Surgical 
Adjuvant Breast Project (protocol 6). II. Relation of local breast recurrence to multicentricity. 
Cancer 1986;57(9):1717–1724. 
53. 
Kurtz JM, Amalric R, Brandone H, et al. Local recurrence after breast-conserving surgery 
and radiotherapy. Frequency, time course, and prognosis. Cancer 1989;63(10):1912–1917. 
54. 
Kuske RR, Winter K, Arthur DW, et al. Phase II trial of brachytherapy alone after 
lumpectomy for select breast cancer: toxicity analysis of RTOG 95–17. Int J Radiat Oncol Biol 
Phys 2006;65(1):45–51. 
55. 
Leonard KL1, Hepel JT, Hiatt JR, Dipetrillo TA, Price LL, Wazer DE. The effect of dose-
volume parameters and interfraction interval on cosmetic outcome and toxicity after 3-
dimensional conformal accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys. 2013 
Mar 1;85(3):623-9 
56. 
Kriege M, Brekelmans CT, Boetes C, et al. Efficacy of MRI and mammography for breast-
cancer screening in women with a familial or genetic predisposition. N Engl J Med 
2004;351(5):427–437. 
57. 
Lehman CD, Blume JD, Thickman D, et al. Added cancer yield of MRI in screening the 
contralateral breast of women recently diagnosed with breast cancer: results from the 
International Breast Magnetic Resonance Consortium (IBMC) trial. J Surg Oncol 2005;92(1):9–
16. 
58. 
Hylton N. Magnetic resonance imaging of the breast: opportunities to improve breast 
cancer management. J Clin Oncol 2005;23(8):1678–1684. 
59. 
Esserman L, Hylton N, Yassa L, et al. Utility of magnetic resonance imaging in the 
management of breast cancer: evidence for improved preoperative staging. J Clin Oncol 
1999;17(1):110–119. 
60. 
Buchanan CL, Morris EA, Dorn PL, et al. Utility of breast magnetic resonance imaging in 
patients with occult primary breast cancer. Ann Surg Oncol 2005;12(12):1045–1053. 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 32 of 39 
 
61. 
Chen X, Quiao Q, Currey A, et al.. Online adaptive replanning for sequential boost after 
whole breast irradiation (abstract). American Association of Physicist in Medicine (AAPM) 55th 
Annual Meeting, August 4-8, 2013, Indianapolis, IN. 
62. 
Stegman LD, Beal KP, Hunt MA, et al. Long-term clinical outcomes of whole-breast 
irradiation delivered in the prone position. Int J Radiat Oncol Biol Phys 2007;68(1):73–81. 
63. 
Formenti SC, DeWyngaert JK, Jozsef G, Goldberg JD. Prone vs supine positioning for 
breast cancer radiotherapy. JAMA. 2012 Sep 5;308(9):861-3 
64.Lymberis SC, deWyngaert JK, Parhar P, et al. Prospective assessment of optimal individual 
position (prone versus supine) for breast radiotherapy: volumetric and dosimetric correlations in 
100 patients. Int J Radiat Oncol Biol Phys. 2012 Nov 15;84(4):902-9. 
65. 
Mohammed ZM, Going JJ, Edwards J, McMillan DC. The role of the tumour inflammatory 
cell infiltrate in predicting recurrence and survival in patients with primary operable breast 
cancer. Cancer Treat Rev 2012 Dec;38(8):943-55. 
66. 
Klintrup K1, Mäkinen JM, Kauppila S,et al. Inflammation and prognosis in colorectal 
cancer. Eur J Cancer. 2005 Nov;41(17):2645-54 
67. 
Mohammed ZM, Going JJ, Edwards J, Elsberger B, Doughty JC and McMillan DC.The 
relationship between components of tumour inflammatory cell infiltrate and clinicopathological 
factors and survival in patients with primary operable invasive ductal breast cancer. British 
Journal of Cancer. 2012. 107, 864–873. 
68. 
Brown JR, DiGiovanna MP, Killelea B, Lannin DR, Rimm DL. Quantitative assessment of 
Ki-67 score for predictions of response to neoadjuvant chemotherapy in breast cancer. Lab 
Invest. 2014 Jan 94(1):98-106. 
69. 
Trapnell C, Pachter L, Salzberg SL. TopHat: discovering splice junctions with RNA-Seq. 
Bioinformatics. 2009 May 1;25(9):1105-11. 
70. 
Roberts A, Trapnell C, Donaghey J, Rinn JL, Pachter L. Improving RNA-Seq expression 
estimates by correcting for fragment bias. Genome Biol. 2011;12(3):R22. 
71. 
Trapnell C, Hendrickson DG, Sauvageau M, Goff L, Rinn JL, Pachter L. Differential 
analysis of gene regulation at transcript resolution with RNA-seq. Nat Biotechnol. 2013 
Jan;31(1):46-53. 
72. 
Morrow, M. Personalizing extent of breast cancer surgery according to molecular 
subtypes. Breast Edinb. Scotl. 22 Suppl 2, S106–109 (2013). 
73. 
Cadoo, K. A., Traina, T. A. & King, T. A. Advances in molecular and clinical subtyping of 
breast cancer and their implications for therapy. Surg. Oncol. Clin. N. Am. 22, 823–840 (2013). 
74.     Høyer, M. et al. Advances in radiotherapy: from 2D to 4D. Cancer Imaging Off. Publ. Int. 
Cancer Imaging Soc. 11 Spec No A, S147–152 (2011). 
75. 
Eschrich, S. A. et al. Validation of a radiosensitivity molecular signature in breast cancer. 
Clin. Cancer Res. Off. J. Am. Assoc. Cancer Res. 18, 5134–5143 (2012). 
76. 
Torres-Roca, J. F. A molecular assay of tumor radiosensitivity: a roadmap towards 
biology-based personalized radiation therapy. Pers. Med. 9, 547–557 (2012). 
77. 
Eschrich, S. A. et al. A gene expression model of intrinsic tumor radiosensitivity: 
prediction of response and prognosis after chemoradiation. Int. J. Radiat. Oncol. Biol. Phys. 75, 
489–496 (2009). 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 33 of 39 
 
78. 
Ahn, S. J. et al. Quantitative assessment of tumor responses after radiation therapy in a 
DLD-1 colon cancer mouse model using serial dynamic contrast-enhanced magnetic resonance 
imaging. Yonsei Med. J. 53, 1147–1153 (2012). 
79. 
Carlson, J. J. & Roth, J. A. The impact of the Oncotype Dx breast cancer assay in 
clinical practice: a systematic review and meta-analysis. Breast Cancer Res. Treat. 141, 13–22 
(2013). 
80. 
Bhide, S. A. & Nutting, C. M. Recent advances in radiotherapy. BMC Med. 8, 25 (2010). 
81. 
Lee, D. J., Ahmed, H. U., Moore, C. M., Emberton, M. & Ehdaie, B. Multiparametric 
magnetic resonance imaging in the management and diagnosis of prostate cancer: current 
applications and strategies. Curr. Urol. Rep. 15, 390 (2014). 
82. 
Bhatnagar, P., Subesinghe, M., Patel, C., Prestwich, R. & Scarsbrook, A. F. Functional 
imaging for radiation treatment planning, response assessment, and adaptive therapy in head 
and neck cancer. Radiogr. Rev. Publ. Radiol. Soc. N. Am. Inc 33, 1909–1929 (2013). 
83. 
Chen, J.-H. & Su, M.-Y. Clinical application of magnetic resonance imaging in 
management of breast cancer patients receiving neoadjuvant chemotherapy. BioMed Res. Int. 
2013, 348167 (2013). 
84. 
Wang, C.-H., Yin, F.-F., Horton, J. & Chang, Z. Review of treatment assessment using 
DCE-MRI in breast cancer radiation therapy. World J. Methodol. 4, 46–58 (2014). 
85. 
Schwartz, D. L. Current progress in adaptive radiation therapy for head and neck cancer. 
Curr. Oncol. Rep. 14, 139–147 (2012). 
86. 
Ahn, S. J., An, C. S., Koom, W. S., Song, H.-T. & Suh, J.-S. Correlations of 3T DCE-MRI 
quantitative parameters with microvessel density in a human-colorectal-cancer xenograft mouse 
model. Korean J. Radiol. Off. J. Korean Radiol. Soc. 12, 722–730 (2011). 
87. 
Stephen, R. M. et al. Monitoring the development of xenograft triple-negative breast 
cancer models using diffusion-weighted magnetic resonance imaging. Exp. Biol. Med. Maywood 
NJ 237, 1273–1280 (2012). 
88. 
Zahra, M. A., Hollingsworth, K. G., Sala, E., Lomas, D. J. & Tan, L. T. Dynamic contrast-
enhanced MRI as a predictor of tumour response to radiotherapy. Lancet Oncol. 8, 63–74 
(2007). 
89. 
Dewhirst, M. W. & Chi, J.-T. Understanding the tumor microenvironment and 
radioresistance by combining functional imaging with global gene expression. Semin. Radiat. 
Oncol. 23, 296–305 (2013). 
90. 
Yamamoto, S., Maki, D. D., Korn, R. L. & Kuo, M. D. Radiogenomic analysis of breast 
cancer using MRI: a preliminary study to define the landscape. AJR Am. J. Roentgenol. 199, 
654–663 (2012). 
91. 
Weichselbaum, R. R. et al. An interferon-related gene signature for DNA damage 
resistance is a predictive marker for chemotherapy and radiation for breast cancer. Proc. Natl. 
Acad. Sci. U. S. A. 105, 18490–18495 (2008). 
92.  
Greenup, R. A. et. al. Cost comparison of radiation treatment options after lumpectomy 
for Breast Cancer. Annal Surg Oncol  19:3275-3281 (2012). 
93.  
Stull, T.S. et.al.  Comparison of Oncotype Dx between surgical and core biopsy 
specimens in breast cancer patients. Presented at the San Antonio Breast Cancer Symposium, 
December 6-10, 2011.  

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 34 of 39 
 
94.  
Horton, J.K. et al.  Preoperative single-fraction partial breast radiation therapy: A novel 
phase I, dose-escalation protocol with radiation response biomarkers. Int. J. Radiat. Oncol. Biol. 
Phys. 92:846-855, 2015. 
95. 
Livi, L. et al. Accelerated partial breast irradiation using intensity-modulated radiotherapy 
versus whole breast irradiation: 5-year survival analysis of a phase 3 randomized controlled 
trial. Euro J Cancer. 51:451-463, 2015. 
96. 
Vaidya J.S. et al. Risk-adapted targeted intraoperative radiotherapy versus whole-breast 
radiotherapy for breast cancer: 5-year results for local control and overall survival from the 
TARGIT-A randomized trial. Lancet. 383:603-613, 2014.  
97. 
Thoeny, H.C. et al. Predicting and monitoring cancer treatment Response with diffusion- 
weighted MRI. J of Magnetic Resonance Imaging 32:2-16, 2010. 
98. 
Formenti, S.C. et al. Pre-operative twice-weekly paclitaxel with concurrent radiation 
therapy followed by surgery and post-operative doxorubicin-based chemotherapy in locally 
advanced breast cancer: A phase I/II trial. J Clin Oncol  21:864-870, 2003.  
99. 
Bollet M.A. et al. Pathological response to pre-operative concurrent chemo-radiotherapy 
for breast cancer: Results of a phase II study. Euro J Cancer  42:2286-2295, 2006. 
100. 
Kao J. et al. Concomitant radiation therapy and paclitaxel for unresectable locally 
advanced breast cancer: results from two consecutive phase I/II trials. Int J Radiation Oncology 
Biol Phys. 61(4):1045-1053, 2005. 
101. Kim J.H., et al. Interval between surgery and radiation therapy is an important prognostic 
factor in treatment of rectal cancer. Cancer Res Treat 44(3):187-194, 2012. 
102. Boostrom S.Y. et.al. Incidence of clinically significant seroma after breast and axillary 
surgery. J Am Coll Surg 208(1):148-150, 2009. 
103  Grimsby G.M. et al. Is there concordance of invasive breast cancer pathologic tumor size 
with magnetic resonance imaging?  Am J Surg 198:500-504, 2009.  
104. Simon R. Optimal two-stage designs for phase II clinical trials. Control Clin Trials 10(1):1-
10, 1989. 
105. Ivanova A. Simon's Two-Stage design. Retrieved February 11, 2016, from 
http://cancer.unc.edu/biostatistics/program/ivanova/SimonsTwoStageDesign.aspx  
 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 35 of 39 
 
APPENDIX 1 – Patient Assessments 
Screening 
Assessments 
Within 90 
Days of 
Enrollment 
Within 60 
Days of 
Enrollment 
History and Physical, 
Performance Status and Height 
and Weight Documentation 
 
X 
Biopsy Proven Invasive Breast 
Cancer 
X 
 
Breast Examination 
 
X 
Bilateral Mammogram 
 
X (within 60 
days of 
diagnosis) 
Clip placed in tumor, verified by 
mammogram 
 
X 
CBC w/diff and ANC 
 
X 
Complete Metabolic Panel 
 
X 
Determination of hormone 
receptor and her2 status 
Prior to enrollment 
Ultrasound or MRI of axilla with 
biopsy of any 
enlarged/abnormal lymph 
nodes 
 
X (within 42 
days of 
enrollment) 
Consultation with Medical 
Oncologist 
Prior to enrollment 
If Oncotype or Mammaprint is 
recommended, assessment of 
adequacy of biopsy specimen 
Prior to enrollment 
 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 36 of 39 
 
Assessments During Treatment 
Assessments 
Prior to Start 
of RT 
Last Day of RT 
(+/- 1 treatment) 
History and Physical or weekly 
review, Performance Status and 
Weight Documentation 
X 
X 
Breast Examination 
X 
X 
Adverse event evaluation 
 
X 
Physician Cosmetic and QOL 
Questionnaire 
X 
X 
Breast Photos 
X 
 
Specimens for Research 
(blood, biopsy specimen) 
X 
X (blood only)* 
*Optional for those treated outside Froedtert Hospital 
 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 37 of 39 
 
Follow-up Assessments 
Assessments 
4-6 weeks 
After RT 
Completion 
Within 4-6 
weeks after  Last 
Surgery 
6 Months 
(+/-2wks) 
After 
Surgery 
12 Months (+/- 1 
month) After 
Surgery then 
Annually* (+/- 2 
months)  
History and Physical, 
Performance Status and Weight 
Documentation 
X 
X 
X 
X (until year 5) 
Breast Examination 
X 
X 
X 
X (until year 5) 
Adverse event evaluation 
X 
X 
X 
X (until year 5) 
Specimens for Research 
(Blood, surgical specimen) 
X  
(Blood) 
X (surgical 
specimen) 
 
 
Physician Cosmetic and QOL 
Questionnaire 
X 
X 
X 
X (until year 5) 
Breast Photos 
 
X 
X 
X (until year 3) 
Breast MRI 
X 
 
 
 
Mammogram of Ipsilateral Breast 
 
 
X 
 
Mammogram of Bilateral Breasts* 
(based on surgical date) 
 
 
 
X (until year 5)** 
*Follow-up and mammogram interval of every 12 months +/- 2months will be calculated from the 
actual date of the previous follow-up visit or mammogram. 
**The mammogram to be done 12 months (+/- 1 month) after surgery is optional based on 
standard of care mammography schedules.  

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 38 of 39 
 
APPENDIX II 
ZUBROD/ECOG PERFORMANCE SCALE 
0 Fully active, able to carry on all predisease activities without restriction 
 
1 Restricted in physically strenuous activity but ambulatory and able to carry work of a light 
or sedentary nature. For example, light housework, office work. 
 
2 Ambulatory and capable of self-care but unable to carry out any work activities. Up and 
about more than 50% of waking hours. 
 
3 Capable of only limited self-care, confined to bed or chair 50% or more of waking hours 
 
4 Completely disabled. Cannot carry on self-care. Totally confined to bed 
 
5 Death 
 
KARNOFSKY 
100 – Normal; no complaints; no evidence of disease. 
90 – Able to carry on normal activity; minor signs or symptoms of disease. 
80 – Normal activity with effort; some signs or symptoms of disease. 
70 – Cares for self; unable to carry on normal activity or to do active work. 
60 – Requires occasional assistance, but is able to care for most of their personal needs. 
50 – Requires considerable assistance and frequent medical care. 
40 – Disabled; requires special care and assistance. 
30 – Severely disabled; hospital admission is indicated although death not imminent. 
20 – Very sick; hospital admission necessary; active supportive treatment necessary. 
10 – Moribund; fatal processes progressing rapidly. 
0 – Dead. 
 
 

 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI  
Page 39 of 39 
 
 
 
APPENDIX III  
PHYSICIAN SCORED COSMETIC RESULTS 
Please circle the result that best describes the breast appearance 
1 
EXCELLENT:  When compared to the untreated breast or the original appearance of 
the breast, there is minimal or no difference in the size or shape of the treated breast. 
The way the breast feels (its texture) is the same or only slightly different. There may be 
thickening scar tissue or fluid accumulation within the breast, but not enough to change 
the appearance. 
2 
GOOD: There is slight difference in the size or shape of the treated breast as compared 
to the opposite breast or the original appearance of the treated breast. There may be 
some mild reddening or darkening of the breast. The thickening or scar tissue within the 
breast causes only a mild change in the shape or size. 
3 
FAIR:  Obvious difference in the size and shape of the treated breast. This change is a 
quarter or less of the breast. There can be moderate thickening or scar tissue of the 
skin and the breast, and there may be obvious color changes. 
4 
POOR:  Marked change in the appearance of the treated breast involving more than a 
quarter of the breast tissue. The skin changes may be obvious and detract from the 
appearance of the breast. Severe scarring and thickening of the breast, which clearly 
alters the appearance of the breast, may be found. 
 
Please circle a number of each of the following treatment effects. 
 
None 
Yes, present but does 
not affect cosmesis 
Yes, present and 
affects cosmesis 
Skin Telangectasia 
0 
1 
2 
Skin Atrophy 
0 
1 
2 
Scarring 
0 
1 
2 
Pigment Change 
0 
1 
2 
Erythema 
0 
1 
2 
Fat Necrosis 
0 
1 
2 
Fibrosis 
0 
1 
2 
Retraction or 
Contour Defect 
0 
1 
2 
Volume Loss 
0 
1 
2 
Other significant 
Treatment Effects 
0 
1 
2 
Specify: 
 
Comments: 
 
 
Assessment Time Point (Circle one):  
Pre-Treatment 
Last Day of RT 
1 Month After RT Completion (Pre-Surgery)     1 month post-op 
6 months     12 months (1yr) 
24 months (2 years) 36 months (3 years)  
48 months (4 years) 60 months (5 years) 
__________________________________   
__________________________________ 
Patient 
Initials 
Physician’s Signature 
Signature Date 
Patient Study ID 
Last          First      Middle 

Version 9,  January 27, 2020  
  
PRO 26847 Currey IIT Pre-Op APBI  
Page 1 of 7 
Page 1 of 7 
  
 
Patient 
Initials 
Last 
First   Middle 
Pre-Operative Accelerated Partial 
Breast Irradiation  
Quality of Life Questionnaire 
  
 
 
 
 
 
 
 
 
 
 
Record the participant's study ID on each of the remaining pages 
before giving the questionnaire to the participant. 
 
 
 
Participants should complete this questionnaire at baseline (after consent and prior to randomization) and at end 
of radiation therapy, one month after radiation therapy (prior to surgery), one month after surgery, 6 months post-
surgery, 12, 24, 36, 48, and 60 months after surgery or chemotherapy whichever is later.  The first page is to be 
completed by a clinical staff member.  Fill in the items listed on this page, print the patient's study ID at the top 
of pages 2 through 7 and give the questionnaire to the patient for completion.  After the patient has completed 
the questionnaire, verify that the date has been recorded at the top of page 2, and submit the completed 
questionnaire to the CRA/CRC in the Clinical Trials Office. 
 
Please administer the questionnaire at an office visit if possible.  If that is not possible, mail the questionnaire to 
the patient, then call to ask for the patient's responses over the phone.   
 
Staff Member Administering Form 
Last Name 
First Name 
Phone 
This form is being filled out:  (Mark one.) 
By participant in doctor's office 
By clinical staff, on phone with participant 
By participant not in doctor's office 
Other 
,
Patient Study ID 
2 years after surgery  
 
 
3 years after surgery  
 
 
4 years after surgery  
 
 
5 years after surgery  
 
Baseline (after consent, prior to radiation) 
Last Day of radiation therapy 
4 weeks (1 month) after the end of radiation 
therapy (prior to surgery) 
1 month post-surgery 
6 months post-surgery 
12 months after surgery  
(whichever is later) 
Time point for this questionnaire – Circle One 

 
 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI 
 Page 2 of 7 
 
Patient Study ID 
 
Date this questionnaire is completed:  
Month 
Day 
Year 
(For example, if you were completing the questionnaire on September 8, 2014, you would 
write 09 08 2014 in the boxes.) 
Thank you for completing this questionnaire. 
We are interested in your evaluation of your physical appearance and functioning since you 
have been treated for breast cancer.  Please rate the following items on this four-point scale, 
according to your evaluation at this point in time. 
Difference between treated and untreated 
breast and area 
None 
Slight 
Moderate 
Large 
 
1 Breast size  
 1 
  
 2 
  
 3 
  
 4 
2 Breast texture (hardening)  
 1 
  
 2 
  
 3 
  
 4 
3 Arm heaviness  
 1 
  
 2 
  
 3 
  
 4 
4 Nipple appearance  
 1 
  
 2 
  
 3 
  
 4 
5 Shoulder movement  
 1 
  
 2 
  
 3 
  
 4 
6 Arm movement  
 1 
  
 2 
  
 3 
  
 4 
7 Breast pain  
 1 
  
 2 
  
 3 
  
 4 
8 Ability to lift objects  
 1 
  
 2 
  
 3 
  
 4 
9 Fit of shirt sleeve  
 1 
  
 2 
  
 3 
  
 4 
10 Breast tenderness  
 1 
  
 2 
  
 3 
  
 4 
11 Shoulder stiffness  
 1 
  
 2 
  
 3 
  
 4 
12 Breast shape  
 1 
  
 2 
  
 3 
  
 4 
13 Breast elevation (how high the breast is)  
 1 
  
 2 
  
 3 
  
 4 
14 Scar tissue  
 1 
  
 2 
  
 3 
  
 4 
15 Shoulder pain  
 1 
  
 2 
  
 3 
  
 4 
16 Arm pain  
 1 
  
 2 
  
 3 
  
 4 
17 Arm swelling  
 1 
  
 2 
  
 3 
  
 4 
18 Breast swelling  
 1 
  
 2 
  
 3 
  
 4 
19 Arm stiffness  
 1 
  
 2 
  
 3 
  
 4 
20 Fit of bra  
 1 
  
 2 
  
 3 
  
 4 
21 Breast sensitivity  
 1 
  
 2 
  
 3 
  
 4 
22 Fit of clothing  
 1 
  
 2 
  
 3 
  
 4 
 
 
 
 
 
 
 
 
 
 

 
 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI 
 Page 3 of 7 
 
Patient Study ID 
 
We are interested in your personal reactions to the radiation and surgery you have received for your 
breast cancer. Please answer the following questions by circling one (1) number.  Please note that the 
response options are labeled at the end-points only.  However, you can and should use all of the points 
on the scale as appropriate to best convey your response. This page should be filled out only one 
month after radiation and one month after surgery 
1. To what extent has your radiation/surgery disrupted your normal daily activities? 
 
 
Not at all 
A lot 
2. To what extent has your surgery/radiation disrupted your normal recreational activities? 
 
 
Not at all 
A lot 
3. To what extent has your radiation/surgery disrupted your normal activities with your 
family and friends? 
 
 
Not at all 
A lot 
4. To what extent has your radiation/surgery disrupted your normal sleep pattern? 
 
 
Not at all 
A lot 
5. To what extent has your radiation/surgery reduced your enjoyment of life? 
 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Not at all 
A lot 
6. To what extent has your radiation/surgery disrupted your regular activities at work (e.g., 
need to take time off, not getting done as much as you'd like)?  If you do not work outside 
the home for pay, please check this box and go to the next question. 
 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Not at all 
A lot 
7. How satisfied are you with the length of time your treatment has taken to this point in time? 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Not at all 
A lot 
8. How disruptive has your radiation/surgery been to the other important people in your life (e.g., 
family and close friends)? 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Not at all 
A lot 
 
 
 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 

 
 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI 
 Page 4 of 7 
 
Patient Study ID 
 
These questions are about how you feel and how things have been with you during the past 4 
weeks. For each question, please give the one answer that comes closest to the way you have 
been feeling. 
 
How much of the time during the past 4 weeks... 
All 
of the 
time 
 
Most 
of the 
time 
 
Some 
of the 
time 
 
A little 
of the 
time 
 
None 
of the 
time 
 
1. Did you feel full of life? 
1   
2   
3   
4   
5 
2. Did you have a lot of energy? 
1   
2   
3   
4   
5 
3 Did you feel worn out? 
1   
2   
3   
4   
5 
4. Did you feel tired? 
1   
2   
3   
4   
5 
 
5. Rate your pain at its worst in the past four weeks.  (Circle one number.) 
 
 
No pain 
Pain as bad as you 
can imagine 
6. Rate your pain at its least in the past four weeks.  (Circle one number.) 
 
 
No pain 
Pain as bad as you 
can imagine 
7. Rate your pain on average in the past four weeks.  (Circle one number.) 
 
 
No pain 
 
8. Rate how much pain you have right now.  (Circle one number.) 
Pain as bad as you 
can imagine 
 
 
No pain 
Pain as bad as you 
can imagine 
9. Are you currently receiving treatments or taking medications for your pain? 
Circle one: 
Yes No 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 

 
 
 
Version 9, January 27, 2020  
PRO 26847 Currey IIT Pre-Op APBI 
 Page 5 of 7 
 
Patient Study ID 
 
 
By circling one (1) number per line, please indicate how much you have been 
bothered by each of the following problems in the past four weeks.
Not 
bothered 
at all 
A little bit 
bothered 
Some- 
what 
bothered 
Bothered 
quite 
a bit 
Bothered 
very 
much 
 
Fever or shivering (shaking, chills) 
0   
1   
2   
3   
4 
Swelling of breast (breast feels larger) 
0   
1   
2   
3   
4 
Breast heaviness 
0   
1   
2   
3   
4 
Breast warm to touch 
0   
1   
2   
3   
4 
Breast skin is red 
0   
1   
2   
3   
4 
Breast skin is tanned 
0   
1   
2   
3   
4 
Breast skin or area around nipple is pale in 
0 
color 
  
1   
2   
3   
4 
Breast skin is flaking or peeling 
0   
1   
2   
3   
4 
Bleeding or fluid leakage from breast 
0   
1   
2   
3   
4 
Breast itching 
0   
1   
2   
3   
4 
Blisters on the breast (or breast skin moist 
0 
and raw) 
  
1   
2   
3   
4 
Coughing 
0   
1   
2   
3   
4 
Difficulty breathing 
0   
1   
2   
3   
4 
Muscle aches 
0   
1   
2   
3   
4 
Rib or chest wall pain 
0   
1   
2   
3   
4 
Infections 
0   
1   
2   
3   
4 
Slow healing of breast wounds 
0   
1   
2   
3   
4 
Visible small blood vessels (spider veins) 
0   
1   
2   
3   
4 
Pockmarks or puncture wounds on breast 
0   
1   
2   
3   
4 
Thickening of breast skin 
0   
1   
2   
3   
4 
Hardening of breast 
0   
1   
2   
3   
4 
Breast or nipple numbness 
0   
1   
2   
3   
4 
Sharp shooting pains or twinges in the 
0 
breast 
  
1   
2   
3   
4 
 

 
Version 9, January 27, 2020  
 
PRO 26847 Currey IIT Pre-Op APBI 
Page 6 of 7  
 
Patient Study ID 
 
Not 
bothered 
at all 
A little 
bit 
bothered 
Some- 
what 
bothered 
Bothered 
quite 
a bit 
Bothered 
very 
much 
 
Breast aches 
0 
1 
2 
3 
4 
Breast tenderness 
0 
1 
2 
3 
4 
Decrease or lack of arousal on breast 
0 
1 
2 
3 
4 
Any other problems? (Specify below) 
0 
1 
2 
3 
4 
 
 
You have been treated with breast conserving therapy for breast cancer. As you know, a reason for 
choosing this treatment is to keep a breast that looks and feels as close to normal as possible. Your 
opinion concerning the appearance of your breast is valuable to us. Circle the number next to the 
word that best describes how your breast looks now. 
 
1 
EXCELLENT:  when compared to the untreated breast or the original appearance of the 
breast, there is minimal or no difference in the size or shape of the treated breast. The 
way the breast feels (its texture) is the same or slightly different.  There may be 
thickening, scar tissue or fluid accumulation within the breast, but not enough to change 
the appearance. 
2 
GOOD:  there is a slight difference in the size or shape of the treated breast as 
compared to the opposite breast or the original appearance of the treated breast. There 
may be some mild reddening or darkening of the breast. The thickening or scar tissue 
within the breast causes only a mild change in the shape or size. 
3 
FAIR: obvious differences in the size and shape of the treated breast. This change 
involves a quarter or less of the breast. There can be moderate thickening or scar tissue 
of the skin and the breast, and there may be obvious color changes. 
4 
POOR:  marked change in the appearance of the treated breast involving more than a 
quarter of the breast tissue. The skin changes may be obvious and detract from the 
appearance of the breast. Severe scarring and thickening of the breast, which clearly 
alters the appearance of the breast, may be found. 
 
My satisfaction about the treatment and results is: (Select the phrase that best describes your 
satisfaction.) 
 
 
 
 
 
 
Totally 
satisfied 
Somewhat 
satisfied 
Neither 
satisfied nor 
dissatisfied 
Somewhat 
dissatisfied 
Totally 
dissatisfied 
Specify other problems: 

 
Version 9, January 27, 2020  
 
PRO 26847 Currey IIT Pre-Op APBI 
Page 7 of 7  
 
Patient Study ID 
 
 
Before any treatment to your breast, the size of your breasts was: (Select the phrase that best 
describes your breast size prior to treatment.) 
 
 
 
 
Larger 
on left 
The same on 
both sides 
Larger 
on right 
 
The size of your breasts now is: (Select the phrase that best describes your breast size now.) 
 
 
 
 
 
Larger 
on left 
The same on 
both sides 
Larger 
on right 
 
 
Thank you for completing this questionnaire!