reverse boost in breast cancer

7/31/2019 Reverse Boost in Breast Cancer

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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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reverse boost in breast cancer

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