Nitesh N. Paryani, M.D. First Radiation & Oncology Group Instructor of Radiation Oncology, Mayo Clinic Courtesy Professor, University of Florida

Transcription

1 Nitesh N. Paryani, M.D. First Radiation & Oncology Group Instructor of Radiation Oncology, Mayo Clinic Courtesy Professor, University of Florida

2 I Invasive Breast Brachytherapy

3 Non-invasive Image-guided Breast Brachytherapy (AccuBoost System) Novel technique for partial breast irradiation Non-invasive Breast immobilization Image-guidance Collimated photon emissions using Tungsten alloy applicators Utilizes HDR Ir-192 source

4 AccuBoost System X-ray Tube Compression Plates Applicators for HDR Ir-192 source Imaging Cassette

5 NIBB Treatment Delivery Breast Compression kv imaging in immobilized position

6 Applicator Selection Tumor bed targeted with a 6cm Round Applicator

7 Process is repeated in an orthogonal axis Breast Compression kv imaging in immobilized position

8 Round/Cone Applicator Options Dose Rate Optimized Skin Dose Optimized Standard Round

9 The pathologic anatomy of breast cancer results in the highest concentration of residual tumor cells at or near the tumor bed. As such, a radiation boost is delivered in addition to whole breast radiotherapy

10 5318 pts with Stage I-II BrCa s/p BCT Randomized 50Gy and no boost 50Gy and 16Gy boost 10yr Local Failure No Boost: 10.2% Boost: 6.2% p<0.0001

11 The challenge of the Boost Deliver the dose where it is needed

12 1. Scar based 2. Palpation 3. CT-based 4. Ultrasound How do we (currently) determine the radiation therapy target (Boost)?

13 Palpation Based Planning TB determined by palpation of postsurgical changes and seroma Using other clinical information to aid volume determination

14 Scar Based Planning TB 2-3cm margin around scar Scar

15 Red J, 2007 Methods: 30 pt with 31 breast cancer Accuracy of scar based planning (SBP) was evaluated using CT based delineation of the tumor bed SBP consisted of 3cm margin around the scar Results: SBP failed to cover the TB in 53.8% CT based planning should be used to plan e- boost

16 Fig 3. Cumulative incidence of ipsilateral breast cancer recurrence according to age Randomized trials used standard boost targeting techniques that are known to miss a portion of the tumor bed in at least 50% of cases 18% Bartelink, H. et al. J Clin Oncol; 25: As such, even with a boost, the local failure rate remains high Copyright American Society of Clinical Oncology

17 Fig 3. Cumulative incidence of ipsilateral breast cancer recurrence according to age 18% 9%?? Bartelink, H. et al. J Clin Oncol; 25: The potential improvement inherent with better boost targeting Copyright American Society of Clinical Oncology

18 In recent years, the focus has been on CT-based planning as a means to improve the accuracy of boost delivery. However, there are many limitations to CT-based planning.

19 High resolution (fan beam) planning CT: Where s the tumor bed?

20 ? CT = Guess work High resolution (fan beam) planning CT: Where s the tumor bed? CT is a notoriously inaccurate way to evaluate the tumor bed.

21 Two cases: one easy and one hard. CT- based target delineation by four prominent Harvard faculty radiation oncologists.

22 Radiother and Oncol 93 (2009) 87-93

23 Al Uwini S, et al Radiother and Oncol 93 (2009) Investigate the effect of CT-based delineation on the irradiated boost volume Clinically-based boost planning (EORTC trial) vs CTbased boost planning (Young Trial) Controlled for tumor diameter, irradiation technique (photons vs electrons), lumpectomy size, and age

24 Al Uwini S, et al Radiother and Oncol 93 (2009) Boost type Clinically-based V 95% CT-based V 95% Photons 99 cc 178 cc Electrons 98 cc 150 cc P - value

25 Clinicians appreciate the importance of the boost for local control and fear underdosing. Typical boost volume as determined by current practice and techniques- GO BIG! But, there is a cost to pay.

26 Electron Boost Isodose Plan The fuzzy edge PTV (in blue) = tumor bed plus 5 mm margin. Dose is prescribed to the 90% isodose line Isodose lines: 100% red 90% blue 50% purple 30% brown

27 Fig 4. Cumulative incidence of moderate or severe fibrosis after 50 Gy irradiation or 50 Gy irradiation and a boost of 16 Gy Treating a large volume of breast tissue with the boost has clear cosmetic (and functional) consequences Bartelink, H. et al. J Clin Oncol; 25: Copyright American Society of Clinical Oncology

28 Fibrosis and cosmetic compromise associated with a large volume tumor bed boost

29 AccuBoost improves targeting accuracy whilst minimizing normal tissue irradiation Mammography-based image guidance Minimizes set up inaccuracy Eliminates breast motion Eliminates patient motion Eliminates respiratory motion

30 AccuBoost vs. Electrons

31 AccuBoost vs. Electrons PTV PTV D max PTV D min AccuBoost 44 cc 2.3 cc 1.8 cc Electrons 69 cc 2.3 cc 1.1 cc P-value 0.02 N.S. 0.02

32 AccuBoost vs. Electrons Chest wall max Lung max Skin max AccuBoost 31 cgy 18 cgy 91 cgy Electrons 214 cgy 200 cgy 229 cgy P-value

33 August 1, 2012

34 Update of a Multi-Center Clinical Data Registry of Non-Invasive Image-Guided Breast Brachytherapy for Tumor Bed Boost Jessica Schuster, MD, Virginia Commonwealth University, Richmond, VA Chris Chipko, B.S, Siddharth Saraiya, MD Subarna Hamid, M.D., Ph.D., Kathy Rocchio, M.S., Robyn Vera, M.D., Sandra Sha, M.D., Michele Jolly, M.S., Eric Wooten, B.S., Rashmi Benda, M.D., Scot Ackerman, M.D., Robert Kuske, M.D., Coral Quiet, M.D., Margaret Snyder, R.N., CCRP, Anand M Kuruvilla, M.D, Johnny Kao, M.D., Jaroslaw Hepel, and David E. Wazer, M.D, & Douglas Arthur, M.D.

35 Study Design Privacy encrypted, IRBapproved, online data registry 11 Independent Sites N = 341 women ptis-t2, N0-1 breast cancer Treated with BCS, adjuvant WBRT and tumor bed boost with NIBB 39.6% from academic and 60.4% from communitybased institutions

36 Number of Patients Number of Patients Trends for CTC (v3.0) Toxicity Skin Toxicity Acute Intermediate Late Grade 1 Grade 2 Grade 3 Subcutaneous Toxicity Acute Intermediate Late Grade 1 Grade 2 Grade 3 No Late Grade 3 Toxicity Grade 2 or Greater Acute 1-3 wks Skin 9.7% (n = 22) SubQ - 1.1% (n = 4) Intermediate 4-26 wks Skin % (n = 31) SubQ 3.8% (n = 13) Late-inter > 26 wks Skin - 2.2% (n = 5) SubQ - 3.5% (n = 8)

37 Hypofractionated Tumor Bed Boost Hypofractionated whole breast radiation therapy has become a convenient alternative for many patients. Some of these patients benefit from the addition of a tumor bed boost, however, there is no standard approach to deliver hypofractionated boost. As part of the boost registry, we will be evaluating: 42.5Gy whole breast (2.66 x 16 fractions) followed by Accuboost 2.66Gy x 3 fractions All Accuboost users are welcome to participate in the Boost Registry.

38 Electrons for peri-areolar tumor bed

39 Large sub-areolar tumor bed (peri-areolar incision): One year after 18 Gy from AccuBoost

40 Electrons AccuBoost Intelligent Image-guided radiation therapy Limit normal breast irradiated volume by: 1. Specimen orientation 2. Identification of margin at risk 3. Treat only the tissue at risk!

41 Accelerated Partial Breast Irradiation (APBI)

42 Is APBI still relevant? In order for APBI to be relevant, APBI techniques must have a favorable profile in regards to: Efficacy Toxicity Convenience Cost

43 Lessons Learned from 3D-CRT APBI 31% 7.5% 11% 19% Toxicity Higher rate of late tissue toxicity Higher rate of fair/poor cosmesis Hepel et al., IJROBP 2009;75: Jagsi et al. IJROBP 2010;76:71-8. Leonard et al., IJROBP, 2013;85:623-9 Olivotto et al. JCO, 2013;31:

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45 Potential for a favorable profile in regards to convenience, toxicity, and cosmetic outcomes. NIBB to deliver APBI: Potential Advantages Non-invasive More acceptable to many patients Conformal Treatment No-to-minimal heart and lung exposure (similar to other APBI techniques) Breast immobilization and image-guidance Precision treatment No need for large PTV margins Smaller irradiated volumes Compression displaces non-target breast tissue out of radiation field Potential for decrease in late tissue toxicity Oncoplastic reconstruction can be utilized Decrease risk of persistent seroma

46 NIBB for APBI Accrual completed Fall of patients completed protocol treatment

47 Results Treatment tolerability Treatment was well tolerated by all patients Treatment time Average treatment time per axis: 14 min (range 5-20 min) Average time from start of first axis to completion of orthogonal axis: 43 min (range min) Discomfort during breast compression Median score: 1 (range 0-7) (10 point pain scale)

48 Results Grade 0 Acute Skin Reaction No skin reaction (Gr 0): 8pts (20%) Faint erythema (Gr 1): 21pts (53%) Moderate erythema (Gr 2): 11pts (28%) No pt developed Gr 3 skin reaction or moist desquamation. Maximum skin reaction typically seen after completion of treatment to 2 weeks. Grade 1 Grade 2 Resolved 2 weeks later

49 New protocol in development: Pre-operative NIBB APBI

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