Técnicas y tipos de implantes intersticiales. Mauricio Cambeiro Oncología Radioterápica Clínica Universidad de Navarra
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1 Técnicas y tipos de implantes intersticiales Mauricio Cambeiro Oncología Radioterápica Clínica Universidad de Navarra
2 Multi-catheter Breast Implant (MBI): 1. Brief MBI generalities & classification 2. Close MBI: technical details & image guide 3. Open MBI: technical details (video 1.2 ) 4. Considerations about close or open MBI 5. Results of comparative study of APBI trough POSTMBI vs. FHIOMBI 6. New perspectives after APBI trough FHIOMBI
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4 Delayed Close (MBI) More than 25 years on road Christie Hospital Manches ter(1990) Guy's Hospital London (1991) Polgar C. Budapest (1996) Ochsner clinic Experience (Phase I-II-1992) Robert Kuske
5 RTOG 95-17(B-39/RTOG 0413) 3.4 Gy x 10 Eq2Gy= 41.9 Gy HDR-BT (GEC-ESTRO) 4.3 Gy x 7 / 4.0 Gy x 8 Eq2Gy= Gy (Hungarian) 5.2 Gy x 7 Eq2Gy= 55.8 Gy
6 Careful attention to the implant quality is critical, as dose optimization cannot compensate for a poorly placed implant Coverage TB 1-2 cm MBI Geometry cm Orientation -Coverage -Cosmetic
7 Paris Dosimetry System & MBI procedures Prescribed Dose (PD) Dose Intends to give PD or MTD Dose at periphery of CTV Ideally the same as PD Geometric Center Doses (GCD): Dose at central point within Triangle Mean Central Dose (MCD): Average of all GCD in the central plane Dose Homogeneity Index (DHI) Ratio of MCD/PD DHI=0.85
8 Prescription & Constraints CTV D90 > 90% V100 > 90%
9 MBI Close Cavity procedure Open Cavity procedure PO IO
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11 1. Post-operative (delayed) close cavity procedure MIB Advantages Is the most conformal technique Pioneering, effective & safe for PBI Proper selection patients for PBI Close Delayed MIB
12 Technical considerations in close delayed MIB #2 Encompass TB #1 Location TB #3 Orientation & Geometry
13 Localization tumor bed in close delayed MIB Clinical methods: Pre-operative notes Clinical palpation Surgical scar Pre-surgical mammo/ultrasound Image Guide localization: Clips Seroma
14 Localization tumor bed in close delayed MIB Seroma alone decreases over time and may under-estimate TB. CT recognition is superior to clinical markup (1-4). Current gold standard for TB localization Surgical clips & post-operative 3D-imaging 1. Machtay M, et al. Inaccuracies in using the lumpectomy scar for planning electron boosts in primary breast carcinoma. IJROBP Bedwinek J. Breast conserving surgery and irradiation: the importance of demarcating the excision cavity with surgical clips. IJROBP Harrington KJ, et al. Surgical clips in planning the electron boost in breast cancer: a qualitative and quantitative evaluation.. IJROBP Krawczyk JJ, et al. The importance of surgical clips for adequate tangential beam planning in breast conserving surgery and irradiation. IJROBP 1999
15 Localization tumor bed & Clips placement: Titanium clips allow accurate tumor bed localization following BCS Generally are placed according to protocol during IO procedure: Anterior (close to the suture line) lateral or external Superior wall Inferior wall Medial or internal Posterior (pectoral fascia) Coles C, et al. Eur J Surg Oncol. 2009
16 Radiological assistance for Location tumor BED & guided implant in close MBI US Portable Inexpensive Relatively Simple Good for TB location (+/-clips) Artefact for guided implant CAT SCAN/MRI FLUOROSCOPY Non Portable Expensive Good for TB location (+/-clips) Guided limited by radiation Hazard CT Scan standard for 3D planning Portable Relatively Inexpensive Relatively Simple Good for TB location (+ clips) Non artefact for guided
17 1. TB: largest hypoechoic region in each cardinal direction 2. Implant geometry designed: entry and exit points are marked on the skin 3. Real-time US guidance are inserted one by one. 4. Deepest plane first and then to work more superficially 5. A template can be used. 6. Trajectory of needles needs to be carefully considered
18 1. CT scan: orientation of implant rendering of TBED and patient anatomy. 2. Few needles in the deep plane 3. CT scan: can be used for an initial evaluation of target coverage 4. Remaining needles are inserted in a standard pattern with cm separation
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20 Protocol Surgery + Implant 3D Planning AP = GEC ESTRO (Bajo & Interm.) PBI 34 Gy (3.4 Gy B.I.D 5 days) Mar. Día #1 Mier. Día #2 Juev. Día #3 Vier. Día #4 Sab. Día #5 Dom. Día #6 Lun. Día #7 Mar. Día #8 Mier. Día #9 Juev. Día #10 Vier. Día #11 Remove drain CT AP = GEC ESTRO high risk HDRBT Gy (3.4 Gy B.I.D 2 days) RT (WBI 39.9 Gy)
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22 5. Dosimetría y Restricciones 5.5 Visualización de Isodosis en CTV, zona de densidad clips y OAR
23 5. Dosimetría y Restricciones 5.6 Histogramas Dosis Volumen CTV D90=100% CTV D90=100%
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25 Delayed close cavity Multi-catheter breast implant MIB Disadvantages Classic MIB is usually performed as closed-cavity procedure Indirect visualization of tumor bed Second Invasive procedure Extensive Implants Classic Close Cavity Procedure
26 Emerging APBI techniques
27 FHIOMBI & APBI as competitive technique against Emerging techniques
28 FHIOMBI increase APBI procedures from 6/year to 30/year
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33 Risk groups GEC-ESTRO criteria Low risk Intermediate risk High risk ASTRO criteria Suitable Cautionary Unsuitable All Patients N= /128 (78.9%) 23/128 (17.9%) 4/128 (3.1%) 63/128 (49.2%) 39/128 (39.2%) 26/128 (20.0%) POSTMBI N=43 29/43 (67.4%) 11/43 (25.6%) 3/43 (12.5%) 14/43 (32.5%) 17/43 (39.5%) 12/43 (27.9%) FHIOMBI N=85 72/85 (84.7%) 12/85 (14.1%) 1/85 (1.1%) 49/85 (57.6.4%) 22/85 (25.8%) 14/85 (12.3%)
34 Parameter evaluated Early complications Self-limited hemorrhage Wound dehiscence/necrosis Seroma Infection Total complications Late complications Seroma Symptomatic Fat Necrosis Acute RTOG skin or subcutaneous toxicity Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Late RTOG skin or subcutaneous toxicity Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Cosmetic Outcome Excellent Good Fair Poor All Patients N=140 5 (3.5%) 3 (2.1%) 1 (0.7%) 3 (2.1%) 12 (8.5%) 1 (0.7%) 1 (0.7%) 77 (55.0%) 55 (41.4%) 8 (5.7%) 0 0 (42.8%) (40.0%) (11.4%) (2.1%) 0 (31.4%) (53.5%) (10%) (2.1%) POSTMBI N=43 2 (4.6%) (2.3%) 3 (6.9%) (48.8%) 19 (51.1%) 3 (6.9%) 0 0 (72.0%) (9.3%) (9.3%) 3(6.9%) 0 (34.8%) (51.1%) (11.6%) (2.3%) FHIOMBI N=97 3 (3.0%) 3 (3.0%) 1 (1.0%) 2 (2.0%) 9 (9.3%) 1 (1.0%) 1 (1.0%) 56 (57.7%) 36 (37.1%) 5 (5.1%) 0 0 (29.8%) (53.6%) (12.3%) 0 0 (29.8%) (54.6%) (9.2%) (2.0%)
35 Parameter evaluated All Patients POSTMBI vs. FHIOMBI Median duration procedure Median Catheters Median CTV T Median D90 Median V100 Median V150 Median V200 Median DHI 38 min (range, ) 10 (range, 4-22) 48 cc (range, 16-85) 3.4 Gy (range, ) 60.7 cc (range, ) 15.4 cc (range, ) 6.1 cc (range, ) 0.74 (range, ) 91 vs. 25 min (95CI: 46-60) (p=0.0001) 15 vs. 9 catheters (95CI: 5-6.7) (p=0.0001) 46 cc. vs 49 cc (95CI: ) (p=0.1) 3.4 vs Gy (95CI: ) (p=0.1) 84.5 vs cc (95CI: ) (p=0.2) 25.8 vs cc (95CI: ) (p=0.01) 9.7 vs. 5.9 cc (95CI: ) (p=0.002) 0.68 vs (95CI: ) (p=0.002)
36 Parameter evaluated Median follow up Any Failure LR IBT IBTR CLBR LRF DF All Patients N Events (%) & 5-10 year control rates 68 months (range, ) 7 (5%) & 5-10 year control 95-92% 1 (0.7%) & 5-10 year control 98% 2 (1.5%) & 5-10 year control 99-99% 3 (2.3%) & 5-10 year control 98-98% 4 (3.1%) & 5-10 year control 97-95% 0 (0%) & 5-10 year control 100% 3 (2.1%) & 5-10 year control 99-96% POSTMBI vs. FHIOMBI Events & 5 year control 137 vs. 52 months (95CI:-73-98) (p=0.01) (6 vs. 1) 90% vs. 97% (95CI: ) (p=0.1) (1 vs. 0) 97% vs. 100% (p=0.4) (2 vs. 0) 97% vs. 100% (p=0.4) (3 vs. 0) 95% vs. 100% (p=0.08) (3 vs. 1) 95% vs. 98% (p=0.8) (0 vs. 0) 100% vs. 100% (p=n.s) (3 vs. 0) 97% vs. 100% (p=0.4)
37 Institution PROMIS 11 GEC-ESTRO 10 WBH 14 Budapest 16 RTOG Current study N Follow Up (years) Ipsilateral Breast recurrence 0.8% 1.44% 5% 5.4% 6.0% 1.5% Excellent/Good Cosmetic Outcome 84% NR NR 81% 81% 85%
38 Paris System (PDS) CT-based 3-D planning APBI ULTRA APBI
39 #2. Duration GAP 6 a 1 days Fx. 10 a 4 fx. Dosis Fx. 3.4 a 6 Gy DHI Technique ULTRA-APBI Keep Eficacy/Safety OSNA #1. Reduce ratio APBI/Boost #3. Confort Implant Comfort System
40 Median (EUD 2 Gy) in 40 patients of current APBI: 37.7 Gy Prescription Treatment d n t EQ2Gy EQ2Gy (TC) Modality Gy treatments days Gy Gy D90 = 98 % current APBI 3, ,9 38 D90 = 98 % FAST-APBI 6, D90 = 98 % FAST-APBI 6, ,2 33,5 D90 = 98 % FAST-APBI 6, ,4 35 D90 = 98 % FAST-APBI 7, ,3 39,7 D90 = 98 % current BOOST 3, ,8 15,2 D90 = 98 % FAST-BOOST 5, ,5 D90 = 98 % FAST-BOOST 5, ,9 13,2 D90 = 98 % FAST-BOOST 5, ,9 13,9 D90 = 98 % FAST-BOOST 7, ,8 9,9 EUD 2 Gy,5 fx,7 days Gy 37,7 34,3 37,2 38,9 39,7 18,4 16,4 17,3 18,2 14,4 E U D 2 G y,5 fx i n 7 d a y s d i t ln 2 ndi 1 1 / n d it d ln v e i v i i i ln ( 2 ) ( 2 G y ) (1.4 d a y s ) / ( 2 G y ) T d
41 1. APBI with MBI offers excellent long term results for different disease end points, toxicity, and cosmetic. 2. Open MBI technique seems preferable: Avoids a second invasive procedure Promote autonomy of radiation oncologist Reduce risk of geographical failure Improves logistical issues Increase efficiency of implant & radiation
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