Abstract P4-12-21: Implementing a real-time magnetic resonance imaging guided accelerated partial breast irradiation program
Authors: Omari Eenas A. , Gambla Jennifer , Mai Hahn P. , Kittaneh Muaiad , Thomas Tarita O. , Wynn Raymond B. , Sethi Anil , Small William , Refaat Tamer 
Published: March 2020

Abstract
Motivation: Clinical evidence has shown that accelerated partial breast irradiation (APBI) for early stage breast cancer patients result in local recurrence control rates and cosmetic outcomes comparable to whole breast irradiation. Approaches to APBI include brachytherapy, intraoperative radiation therapy and external beam radiation therapy (EBRT). EBRT is the least invasive approach, most widely available, and does not require additional training. For EBRT APBI, based on NSABP B39/RTOG 0413 protocol, the clinical target volume (CTV) is generated by applying a 1.5 cm margin to the lumpectomy bed and the planning target volume (PTV) is generated by applying an additional 1 cm margin from the CTV to account for set up uncertainties.Real-time magnetic resonance imaging guided radiation therapy (MRgRT) allow for reduced treatment margins by decreasing treatment setup uncertainties. In this work, we share our experience in implementing a MRI guided accelerated partial breast irradiation (MRgAPBI) program into a new clinic with a linear accelerator capable of real-time MRI imaging.
Methods: We have surveyed institutions in which rely on MRI guidance for APBI treatments through a comprehensive literature review and onsite visits. These visits included our radiation therapists, physicists, and radiation oncologists. There are two main components in implementing a new radiotherapy program: 1) patient simulation and immobilization techniques, and 2) treatment planning and delivery techniques. These techniques were studied and modified for our clinical workflow.
Results: Literature review revealed a single institution report addressing their MRgAPBI experience. For immobilization, we adopted two techniques observed during two site visits. However, these techniques were later modified to allow for patient customization. For small breasted patients, a foam tube placed along the sternum is used and for large breasted patients, we employed custom made acrylic brackets placed superior to the shoulders which are then built into the patient's immobilization cradle for individualized set up. For patient comfort, the contralateral arm is placed down along the patient’s side, whereas the ipsilateral arm is moved up away from the radiation field. This also allows for lateral clearance for beam selection. For treatment planning, consensus on optimal margin for expansion from the lumpectomy bed is of utmost importance. A single institution MRgAPBI report described a 1 cm expansion from the lumpectomy bed to PTV while NSABP B39 indicated a 2.5 cm expansion. This reduction in margin was justified by the utilization of real-time MRgRT. We have come to consensus to use a 1.5 cm expansion around the lumpectomy cavity, which accounts for the CTV expansion per NSABP B39 and to forgo the PTV expansion given the minimal setup uncertainty with online MRgRT. Our initial experience showed significant changes in the lumpectomy cavity shape and volume when the gap between patient simulation and the start of treatment exceeded a week. We have thus reduced the time between simulation and treatment to 1 week to address this issue.
Conclusion: Implementing a new MRgAPBI program requires a comprehensive evaluation of available resources and published reports, as well as, team visits to expert MRgAPBI centers. Both immobilization techniques and lumpectomy margin expansions for treatment planning should be well thought of prior to starting a similar program. In our experience, time between simulation and treatment of 1 week showed minimal changes in the shape and size of the planning volume. Additional verification will need to be conducted within a prospective setting and larger cohort. In order to setup a successful program, teamwork is essential between all groups including radiation therapists, dosimetrists, physicists, and radiation oncologists.
Citation Format: Eenas A. Omari, Jennifer Gambla, Hahn P. Mai, Muaiad Kittaneh, Tarita O. Thomas, Raymond B. Wynn, Anil Sethi, William Small Jr, Tamer Refaat. Implementing a real-time magnetic resonance imaging guided accelerated partial breast irradiation program [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-12-21.