reverse boost in breast cancer
TRANSCRIPT
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Reverse Boost in treatment ofReverse Boost in treatment of
early stage Breastearly stage Breastcarcinomas.carcinomas.
An AHI ExperienceAn AHI Experience
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Evolution of Breast conserving
treatment Standard Treatment for early stage
Breast carcinoma ( stages 1 and 2) isBreast conserving Surgery (BCS)
+Whole Breast irradiation. Dose and fraction regimes:
50 Gy in 25 fractions in 5 weeks (WBI)
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Advantages of BCTAdvantages of BCT
Very good cosmesis and minimumVery good cosmesis and minimum
psychological trauma.psychological trauma.
The adjuvant radiation --The adjuvant radiation --
:Controls Residual microscopic:Controls Residual microscopic
disease.disease.
:Eliminates occult multicentric cancer:Eliminates occult multicentric cancercells from elsewhere in the breast.cells from elsewhere in the breast.
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BRACHYTHERAPY UNIT ATBRACHYTHERAPY UNIT AT
ARTEMISARTEMIS
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Review of Literatures-Review of Literatures-
Most tumor recurrences after BCTMost tumor recurrences after BCTminus radiation are in the tumor bedminus radiation are in the tumor bedor in close proximity.or in close proximity.
Bartelink ----91% recurrence inBartelink ----91% recurrence insame quadrant, 56% in the originalsame quadrant, 56% in the originaltumor bed, 27% through out breast.tumor bed, 27% through out breast.
Milan III trial85% relapse in tumorMilan III trial85% relapse in tumorcontaining area,15% in othercontaining area,15% in otherquadrant ( same as rates in c/lquadrant ( same as rates in c/lbreast)breast)
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REVERSE BOOST ?REVERSE BOOST ?
Boost dose of radiation is given orBoost dose of radiation is given or
planned Intra or Per operatively .planned Intra or Per operatively .
Followed by whole breast radiationFollowed by whole breast radiation
therapy.therapy.
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Reverse Boost -AdvantagesReverse Boost -Advantages
A boost dose of 10-16 Gy is homogenous,A boost dose of 10-16 Gy is homogenous, It is biologically equivalent to 20 Gy forIt is biologically equivalent to 20 Gy for
tumor effect and 30 Gy for late normaltumor effect and 30 Gy for late normal
tissue effect.tissue effect.
Per operative needle implant to the tumorPer operative needle implant to the tumor
bed.bed.
Decreases geographical miss.Decreases geographical miss.
Avoids second anesthesia.Avoids second anesthesia.
Accurate mapping and targeting of tumorAccurate mapping and targeting of tumor
bed immediately after surgery.bed immediately after surgery.
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Brachytherapy in BreastBrachytherapy in Breast
CarcinomaCarcinoma A way to deliver localized radiationA way to deliver localized radiation
therapy to the breast usingtherapy to the breast using
interstitial cathetersinterstitial catheters
Renewed interest when performed byRenewed interest when performed by
Dr. Robert Kuske in New Orleans inDr. Robert Kuske in New Orleans in
1991 as monotherapy1991 as monotherapy
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Our Experience at ARTEMISOur Experience at ARTEMIS
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Patient EnrollmentPatient Enrollment
Between July 2008 and June 2009Between July 2008 and June 2009
At ARTEMIS Health Institute OncologyAt ARTEMIS Health Institute Oncology
department.department.
30 patients found suitable for BCS30 patients found suitable for BCS 15/30 patients were found suitable for15/30 patients were found suitable for
reverse boostreverse boost
6/15 patients finally received reverse6/15 patients finally received reverseboost implants.boost implants.
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Criterion for selectionCriterion for selection
Unifocal tumor of size
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HK AS PS SS PP MG
AGE 50 55 75 44 46 26
Menopausal
status
pre post post pre post pre
Tumor T2 T2 T4 T2 T2 T2
Nodes N0 N0 N1 N0 N1 N1Margins negative negative negative negative negative negative
Histology IDC IDC IDC IDC IDC IDC
Grade low low low interm interm interm
Receptors positive positive positive positive ER+ve positive
EBRT Yes No Yes Yes Yes Yes
Chemo/AE AE chemo AE AE Chemo AE+Chemo+
Herceptin
Table 1. Patient Characteristics
IDCinfiltrating ductal carcinoma Chemo-chemotherapyInter-intermediate grade AE- anti-estrogen
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METHOD OFMETHOD OF
INTRAOPERATIVE IMPLANTINTRAOPERATIVE IMPLANT PTV=EXCISED CAVITY +2 cm marginPTV=EXCISED CAVITY +2 cm margin
in X axis and 1 cm in Y axisin X axis and 1 cm in Y axis
Treated length was 30%> targetTreated length was 30%> target
length for peripheral isodose diplength for peripheral isodose dip
Holes in template were 10mm apartHoles in template were 10mm apart
and in equilateral triangleand in equilateral triangle
Single and double plane implantsSingle and double plane implants
done according to tumor sizedone according to tumor size
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After implant guiding needlesAfter implant guiding needlesreplaced by flexible cathetersreplaced by flexible catheters
Simulation with 2 orthogonal raysSimulation with 2 orthogonal rays
done next day to define treatmentdone next day to define treatmentlength of each needlelength of each needle
Most peripheral source position wasMost peripheral source position was
5 mm from skin surface.5 mm from skin surface. Max skin dose was 60% ofMax skin dose was 60% of
prescribed doseprescribed dose
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Dose-12-16 Gy in fractions of 3-4 GyDose-12-16 Gy in fractions of 3-4 Gy
each, 6 hrs aparteach, 6 hrs apart Dose prescribed to 10mm fromDose prescribed to 10mm from
surface of implantsurface of implant
First treatment given 48 hrs afterFirst treatment given 48 hrs afterlumpectomylumpectomy
Patient discharged the day afterPatient discharged the day after
removal of catheters inremoval of catheters inbrachytherapy suitebrachytherapy suite
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TreatmentTreatmentMultiplane catheter Based Multiplane catheter Based
Dose-12-16 Gy over 4-5 # 6 hours apartDose-12-16 Gy over 4-5 # 6 hours apart
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NAME Number of catheters/planes
Dwell Positions Volume of implants
Dose prescribed EBRT
HK 13 double planes 286 70 cc 12Gy in 4fractions Yes
AS 6 single plane 114 29.25 cc 18Gy in6 fractions
No
PS 7 single plane 257 44.8 cc 16Gy in4 fractions
Yes
SS 13 double plane 196 79.5 cc 15Gy in5fractions
Yes
PP 8 single plane 279 73.9 cc 15Gy in5 fractions
Yes
MG 13 double plane 195 98 cc 12 Gy in4 fractions
yes
Table 2 Treatment Details
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Results Of BrachytherapyResults Of Brachytherapy
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Other methods of reverse BoostOther methods of reverse Boost
TARGIT (50KV radiation source)TARGIT (50KV radiation source)
Mammosite (interstitial balloonMammosite (interstitial balloon
therapy)therapy)
ELIOT-Electron intraoperativeELIOT-Electron intraoperative
RadiotherapyRadiotherapy
3D conformal radiation3D conformal radiation Salzburg technique9-10 Gy 8MevSalzburg technique9-10 Gy 8Mev
electrons delivered directly to theelectrons delivered directly to the
tumor bed after lumpectomy.tumor bed after lumpectomy.
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MammositeMammosite Leakage of balloons causing highLeakage of balloons causing high
doses to tissues closer to the sourcedoses to tissues closer to the source Cannot be used in large or irregularCannot be used in large or irregular
cavities.cavities.
Dose distribution less homogenousDose distribution less homogenouswith single seedwith single seed Infection rate 16%, andInfection rate 16%, and
telengiectasia >30%telengiectasia >30% Concern about long term morbiditiesConcern about long term morbidities
due to high skin dose anddue to high skin dose andcompression of normal surroundingcompression of normal surrounding
tissues.tissues.
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Intraoperative radiation withIntraoperative radiation with
electrons or KV X Rayselectrons or KV X Rays Limited data of long term and short termLimited data of long term and short term
effects.effects.
Questionable tumor localization.Questionable tumor localization.
High infection rate.High infection rate. Treatment is completed before finalTreatment is completed before final
histopathology reports.histopathology reports.
Operator dependentOperator dependent In TARGIT penetration depth of KV beamsIn TARGIT penetration depth of KV beams
to 5-10mm may be insufficient.to 5-10mm may be insufficient.
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Partial breast irradiationPartial breast irradiation Reduction of the radiation volume to theReduction of the radiation volume to the
volume of the primary disease only.volume of the primary disease only. APBIDose given faster than the standardAPBIDose given faster than the standard
once per day.once per day.
---Typically given twice per day---Typically given twice per dayseparated by 6 hrs for normal tissueseparated by 6 hrs for normal tissuerepair.repair.
Short treatment timeShort treatment time
Overcomes long distance problemsOvercomes long distance problems Cost effectivenessCost effectiveness Low alfa/Beta ratio, so radio biologicallyLow alfa/Beta ratio, so radio biologically
effectiveeffective
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PBI-Arguments againstPBI-Arguments against
WBI is time tested,well tolerated,WBI is time tested,well tolerated,good cosmetic outcome.good cosmetic outcome.
Trials investigating PBI vs. WBITrials investigating PBI vs. WBI
Local Control comparable to WBILocal Control comparable to WBI EBCTCG meta analysis (Lancet 2005)EBCTCG meta analysis (Lancet 2005)
show small but significant survivalshow small but significant survival
advantage in WBIadvantage in WBI Not all studies report low LRR outsideNot all studies report low LRR outside
the tumor cavitythe tumor cavity
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