EARLY STAGE BREAST CANCER AND THE EMERGING ROLE OF IORT
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1 May 13, 2016 EARLY STAGE BREAST CANCER AND THE EMERGING ROLE OF IORT Presenter: Paul B. Fowler, MD Radiation Oncology, MGSH/MUMH 1
2 Objectives: 1. List treatment options for early stage breast cancer. 2. Describe the different ways of delivering radiation as part of breast conserving therapy. 3. List patient and tumor factors that are important in determining a patients suitability for IORT. 4. Describe the process of Intraoperative Radiation Therapy (IORT) for breast cancer. 2 May 16, 2016
3 May 16,
4 Early Stage Breast Cancer NCI Definition: cancer that has not spread beyond the breast or the axillary lymph nodes. This includes ductal carcinoma in situ and stage I, stage IIA, stage IIB, and stage IIIA breast cancers. 4 May 13, 2016
5 Early Stage Breast Cancer by NCI definition is all but Stage 4, but we ll be focusing on Stage May 16, 2016
6 Early Stage Breast Cancer / IORT More select group than NCI definition Tumors less than 2-3 cm No clinically evident lymph nodal spread Unifocal disease 6 May 16, 2016
7 May 16,
8 Treatment options for Local Management of Early Stage Breast Cancer 1. Mastectomy plus axillary node dissection was historically the gold standard. 8 May 16, 2016
9 Treatment Options for Local Management of Early Breast Cancer. 2. Partial Mastectomy, axillary node sampling, radiation to the intact breast. a. standard fractionation 6.5 weeks b. hypo-fractionation Canadian Fractionation 3 weeks. 3. Partial Mastectomy, axillary node sampling, radiation to just the tumor cavity. a. APBI- 2 treatments daily x 5 days b. IORT- 1 treatment at time of surgery. 9 May 16, 2016
10 Present Present Future 6-7 weeks of treatment 5 days twice a day As little as 8 min. during surgery WBRT APBI IORT
11 May 16,
12 Breast Conserving Therapy (BCT) Vs. Mastectomy NSABP B-06 EBCTCG NCI All show that lumpectomy with negative margins plus post operative radiation to whole breast is effective in treating early stage breast cancer. There is no difference in disease-free or overall survival. Slightly higher local recurrence with BCT that dose not effect survival. Good to excellent cosmetic results seen. 12 May 16, 2016
13 May 16,
14 TARGIT Trial inclusion 45 or older Unifocal disease clinically and on Mammogram, MRI was not required. Node negative disease clinically Invasive Ductal or Ductal Carcinoma-in-situ Less than 3 cm. Resection Margin negative. 14 May 16, 2016
15 The Lancet , DOI: ( /S (13) ) Copyright 2014 Vaidya et al. Open Access article distributed under the terms of CC BY-NC-ND Terms and Conditions Figure 1 Local Control in both arms similar as were survival. Survival curves
16 May 16,
17 Who is a candidate for IORT? IORT is new modality, but very similar to APBI is patient selection. Presently we rely on guidelines for APBI to select appropriate patients. IORT clinical trial is also on going and participation is encouraged. Patient factors often help guide treatment choices. 17 May 16, 2016
18 Who is a candidate for IORT Guidelines? 18 May 16, 2016
19 Who is a candidate for IORT Guidelines? 19 May 16, 2016
20 Who is a candidate for IORT Guidelines? Current Xoft Axxent ebx IORT System Trial criteria. -older than 40, not pregnant -tumor less than 3 cm, -Invasive Ductal or Ductal Carcinoma-in-situ -Unifocal disease -Node negative, no LVSI -No previous cancer or XRT -BRCA-1 and 2 carriers, excluded. May 16,
21 May 16,
22 Intraoperative Radiation Therapy (IORT)
23 No Modifications to the OR
24 Tumor Removal and Cavity Evaluation MC418R1 4/12
25 May 16,
26 Balloon Applicator Features Balloon Inflation Valve Drainage Port Valve Drainage Holes x 7 Drainage holes for seroma management to potentially reduce infection and improve dosimetry. Radiolucent Balloon Wall for improved visibility while imaging MC418R1 4/12
27 Electronic Brachytherapy Controller Components Display Screen/ Touch Screen Control Handheld Barcode Scanner Adjustable arm (in storage position) Well Chamber Wheel Brakes
28 ebx Controller Components Display Screen/ Touch Screen Control Handheld Barcode Scanner Adjustable arm (in storage position) Well Chamber Wheel Brakes
29 Miniaturized X-ray Tube : The Electronic Brachytherapy Source The Source Operates at 50 kv and 300 microamps (15 Watts) MC418R1 4/12
30 ebx High Dose, Low Energy Delivers Less Radiation to Critical Structures (heart, lung) Dickler, et al. A dosimetric comparison of MammoSite high dose rate brachytherapy and Xoft Axxent electronic brachytherapy, Brachytherapy (6) 2007, Slide courtesy of Dr. David Wazer MC418R1 4/12
31 May 16,
32 IORT Video at MedStar UMH 32 May 16, 2016
33 Objectives: 1. List treatment options for early stage breast cancer. 2. Describe the different ways of delivering radiation as part of breast conserving therapy. 3. List patient and tumor factors that are important in determining a patients suitability for IORT. 4. Describe the process of Intraoperative Radiation Therapy (IORT) for breast cancer. 33 May 16, 2016
34 May 16,
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