Breast cancer : The use of TomoTherapy® for patients with implant

reconstruction and other challenging cases

Pr Youlia M. Kirova, MD,

Associate Professor of Radiation Oncology,

Department of Radiation Oncology,

Institut Curie, Paris, France

Disclosures

22/04/2019 2

The views expressed in this presentation are those of the presenters and do not necessarily reflect the views or policies of Accuray Incorporated or its subsidiaries. No official endorsement by Accuray Incorporated or any of its subsidiaries of any vendor, products or services contained in this presentation is intended or should be inferred.

An honorarium is provided by Accuray for this presentation

Breast cancer research and treatment:

1. History and Introduction

2. Evolution of the techniques with increasing place of IMRT

3. Advances in volumes coverage

4. Increasing use of TomoTherapy® in patients with breast reconstruction by implant and other challenging cases

3More than 50% of all patients are treated for breast cancer

TODAY

10 Linacs

2 Helical TomoTherapy®

Techniques to decrease the risk of heart, lung toxicitywith increasing homogeneity and dose distribution

Evolution of the techniques with increasing homogeneity

110% 107% 100% 95% 80% 50%

Conventional 3D RT Simplified IMRT

Giraud et al, CanRad 2012

Specific Radiotherapy techniques of the Institut Curie

Classic dorsal decubitus technique

1. Fournier-Bidoz et al, Med Dosim 2012, « Field in the Field »2. Kirova et al, IJROBP 2007, Paroi électrons3. Kirova et al, Radiother Oncol, 2014, DLI4. Liem et al, Can Rad 2014, Tomothérapie

1

2

3

9

IMRT

Classic field Modulated field

.

IMRT Varian 120 ML

IMRT Varian 80 ML

IMRT TomoTherapy®

Capsular contracture following IBR with implant & RT

CC % Re-operation Med. F/U

IBR No. IBR + RT No. RT Protocol no RT with

RT % (mths)

Marseille 2003, 2010 69 47 50Gy/25f 0 17 11 25

New York 2004 143 68 50Gy/25f 40 68 1.2 34

Stockholm 2006 107 24 46Gy/23 15 42 15 60

London 2006 136 44 50Gy/25f 14 39 9 48

Bristol 2008 53 18 50Gy/25f 11 39 22.2 33

Cambridge 2009 120 42 40Gy/15f 0 19 19.5 50

Autologous tissue reconstruction vs implant, with RT

Implant Autologous graft

Median F/U Complications Reoperation

No No mths. % %

Philadelphia, 2004 44 26 28 TRAM:0

Implant:5 2 (implants)

Boston, 2002 18 30 32 TRAM:12 Implant:53

TRAM:8 Implant:42

Long Island, 2008 69 23 38 ATR:9

Implant:55ATR:0

Implant:19

PMRT with immediate breast reconstruction is oftena technical problem

• Chest wall coverage and heterogeneities

• Combination with regional nodal irradiation

• Lung and heart avoidance

• Delay in initiation of radiotherapy

PMRT with immediate breast reconstruction is oftena technical problem

Courtesy Dr Fourquet

Dosimetry of chest wall and IMN RT

Courtesy Dr Fourquet

Impact of IBR on radiation delivery

without reconstruction with reconstruction

n=112 n=106 p

Chest wall coverage 100 78 < 0.0001

Treatment of IMC 93 45 < 0.0001

Lung irradiation 97 83 < 0.0015

Heart protection 92 85 0.14

% optimal dosimetry

Motwani et al. Int J Radiation Oncology Biol Phys, 2006

18

Radiotherapy

and

Reconstruction:

Presentation of

consensus guidelines

Courtesy P. Poortmans

19

- Philip Poortmans

- Birgitte Offersen; Orit Kaidar-Person; Sandra Hol; Miika Palmu

- Charlotte Coles; Ingvil Mjaaland; Liesbeth Boersma

- Alice Ho/Rachel Jimenez; Reshma Jagsi; ElzbietaSenkus-Konefka; Céline Bourgier; Youlia Kirova; Cynthia Aristei; Icro Meattini; Meritxell Arenas; VassilisKouloulias; Gustavo Nader; Boon Chua; Yvonne Zissiadis; Sofia Rivera; Tanja Skyttä; Tanja Marinko; Karolien Verhoeven; Carine Kirkove; Petra Witt Nystroem; Dorota Gabrys; Anna Kirby; Fiona MacNeill; Tine Engberg Damsgaard; Maria Joao Cardoso; Tove Tvedskov …And many others!!!!

Guidelines for RT & BR: Acknowledgements

20

Guidelines for volume definition RT & BR:

Means:

• International core consensus group representing all involved professions.

• Evaluate current practices for treatment preparation using a questionnaire: virtual simulation vs. target volume based.

• Contouring exercise to evaluate current practices.

• Define target volume guidelines for the chest wall after the most common types of breast reconstruction (base = DK trial GL).

• Target volume contouring exercise using the guidelines to evaluate consistency and to compare with current practices. ESTRO guidelines: accepted for publication

in Radiother Oncol

C. Massabeau, Y. Kirova

New IMRT techniques,

TomoTherapy®

Massabeau et al., Med Dosim 2012

Mastectomy with Immediate breast reconstruction: chest wall and LN irradiation

The volume between skin and implant, the pectoral muscle must be included,

This is the first definition in the literature of CTV in this particular situation

The ESTRO Guidelines have been accepted for publication in Radiotherapy Oncology, to follow…

The best photon-electrons technique vs TomoTherapy®

23

TomoTherapy® VS 3D

Massabeau et al, Med Dosim 2012

Joste et al., submitted

Immediate breast reconstruction: today, clinical workHELICAL TOMOTHERAPY® for patients presented with implant breast reconstruction in case of adjuvant radiotherapy for early stage breast cancer: single center experience and review of the literature:

A retrospective study of all patients presented with implant breast reconstruction (IBR) treated by Intensity-Modulated Radiotherapy (IMRT) using HT between 2009 and 2016 . All of these patients were selected because the 3D conformal radiotherapy was not acceptable in terms of dose distribution and/or doses to the organs at risk (OAR). All patients received chest wall irradiation and most received with LN irradiation.We studied 179 consecutive patients with 194 treated breasts with adjuvant HT. Of them 19 (10,6%) were presented with IBR. One sarcoma was excluded. Breast cancer concerned the left side in 44.4% (n=8/18). Median age was 44 years old (range 26-82). Median follow-up was 40 months.Half patient (50%) patients were treated for initial treatment of their BC, half (50%) patients were treated for first BC recurrence

Joste et al., submitted

Immediate breast reconstruction: today, clinical workHELICAL TOMOTHERAPY® for patients presented with implant breast reconstruction in case of adjuvant radiotherapy for early stage breast cancer: single center experience and review of the literature:

PTV1 coverage

PTV1 Mean

dose (Gy) Dmax (Gy)

Dmin (Gy)

D95(%)

Right breast/chest wall 51.1 ± 1.8 57.9 ± 8.5 39.2 ± 2.8 96.1 ± 1.6 Left breast/chest wall 50.1 ± 0.9 57.0 ± 3.3 36.2 ± 2.7 96.6 ± 1.1 All 50.8 ± 1.3 57.4 ± 6.1 37.6 ± 3.1 96.4 ± 1.3 Dmax: minimum dose Dmax: maximum dose D95: percentage of prescribed dose received by 95% of PTV1

Dmin:

Joste et al., submitted

Immediate breast reconstruction: today, clinical workEarly toxicity N=18 (100%) Dermatitis * grade 0 or 1 * grade 2 * grade 3 Oesophagitis * grade 0 or 1 * grade 2 or more

18 (100%) * 13 (72.2%) * 5 (27.8%) * 0

3 (16.7%) * 3 (16.7%) * 0

Implant rupture 0 Transient interruption of treatment for toxicity 1 (5.5%) Late toxicity N=18 (100%) Cutaneous * hyperpigmentation * telangiectasia * breast fibrosis * breast oedema Pulmonary

2 (11.1%) * 1 (5.5%) * 1 (5.5%) * 2 (11.1%) * 0

0 Cardio-vascular 0 Lymphatic 3 (16.7%) Implant * rupture

* 2 (11.1%)

Longer follow-up and larger number of patients is needed to confirm these excellent results…