Contributo della medicina nucleare nei tumori mammari: dal linfonodo sentinella alla IART

Transcription

1 Contributo della medicina nucleare nei tumori mammari: dal linfonodo sentinella alla IART Prof. Giovanni Paganelli Dipartimento delle procedure e tecnologie avanzate, IRST-IRCCS Meldola. Universita degli Studi Ferrara

2 Phase I: Milan I study 1.0 Breast conservation (352) Halsted (349) Months Veronesi U, et al. N Engl J Med, 2002

3 Twenty years ago the challenge was: Can lymphoscintigraphy + radioguided SNB replace axillary dissection?

4 Multiple SNs interpettoral lymph nodes central axillary group internal mammary chain (IMC) subclavian axillary group lateral axillary group subscapular axillary group anterior axillary group lymphatic vessels to anterior mediastinal lymph nodes lymphatic vessels to the controlateral breast lymphatic vessels to diaphragmatic and liver lymph nodes

5 99mTc-labelled colloids (0.3 mci/0.2ml) < 50 nm < 80 nm nm Sulphide Human albumin Human albumin

6 516 randomized cases AXILLARY DISSECTION SENTINEL NODE N-166 N+91 N+93 SN % N+ ( Veronesi, Paganelli,Viale N Eng JMed 03)

7 USE OF SN IN BREAST CANCER Year N. of cases Percentage 1999: 686/ % 2000: 940/ % 2001: 1126/ % 2002: 1428/ % 2003: 1521/ % 2004: 1759/ % 2005: 1810/ % 2006: 2001/ %

8 Indications to SN SNB after breast surgery SNB in multicentric cancer SNB after chemotherapy SNB after SNB SNB in pregnancy SNB in male breast cancer SNB in DCIS Yes Yes Yes Yes Yes Yes OPTIONAL

9 The 2nd Challenge was: Can non palpable breast lesions be localized with radioisotopes?

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11 ROLL In 1996 we pioneered a new technique to remove non palpable breast lesions Paganelli et al., Eur J Nucl Med 1996

12 anterior lateral

13 The surgeon can determine the best incision to reach the tumor with a better aesthetic result

14 This results in high excision accuracy and centring of the lesion within specimen so that it is rarely necessary to radicalize the margins 1 cm.

15 THE FUTURE From ROLL diagnosis to IART therapy

16 Quadrantectomy + SNB + EBRT represent the standard therapy in Early Breast Cancer

17 Open problems with EBRT EBRT post-quadrantectomy requires 6 8 weeks to be completed EBRT may cause side effects and complications (lung heart) The radiation centres are often not easy accessible

18 Acute skin toxicity during RT

19 Women receiving Postoperative Radiotherapy according to distance to RT Center Distance (Miles) % who received RT after Breast Conservative Surgery < > From WF Athas, et al.,2000

20 Can we modify EBRT in early breast cancer?

21 Partial breast Irradiation PBI Intraoperative Radiotherapy IORT / ELIOT

22 Electrons IntraOperative Therapy There are obvious advantages in terms of overall treatment time, patients comfort, cosmetic results, quality of life. ELIOT represents a step to improve the quality of life of breast cancer patients. Veronesi et al., Ann Surg 2005

23 Electrons IntraOperative Therapy However ELIOT is affected by some limitations: Costs Limited targeted area

24 Skin separator Target Collimator

25 Are there other methods to deliver electrons in the operated breast? anterior + + lateral + ROLL: too large injections of 99mTc -MAA

26 I.A.R.T. Avidin Avidin injection during surgery into the tumour bed area

27 IART Intra-operative Avidination for Radionuclide Theraphy

28 In the operative room

29 Dedicated vial for 90Y or 177Lubiotin

30 in the Nuclear Medicine Dept. 16 to 48 hrs post-surgery 90Y-Biotin i.v. injection

31 Total Body anterior view - pt no 25 1h 4h 24h 48h

32 a) Fig. 1 b)

33 IART Phase II study: summary on dosimetry Tumour bed uptake: 8 % (4 % 12%) of IA Avidin injected 100 mg with dedicated syringe Activity: 3.7 GBq of 90 Y-biotin Gy Tumour quadrant: Kidneys: Ur. Bladder: 20 (15 27) 3.7 ( ) 5.2 ( ) BED 23 Gy Safe!

34 1 2 4 Pre surgery Post surgery 3 6 months after EBRT 3 weeks after IART

35 Conclusions IART is safe and it can be applied to all BC conserving surgery in any hospital without dedicated acellerator Dosimetry calculation,based on our phase II trial, supports its use in early breast cancer.

36 The S.A.R.A. Study Standard -vs Accelerated- Radio metabolic Avidinated therapy Phase III, multicenter, randomized, clinical trial to evaluate IART with 90Y-Biotin compared to Standard RT in patients with breast cancer candidate to RT after conservative surgery Giovanni Paganelli IRST, Meldola

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