Reverse Boost in treatment of early stage Breast carcinomas.

An AHI Experience

Evolution of Breast conserving treatment

Standard Treatment for early stage Breast carcinoma ( stages 1 and 2) is Breast conserving Surgery (BCS) +Whole Breast irradiation. Dose and fraction regimes: 50 Gy in 25 fractions in 5 weeks (WBI)

Advantages of BCT

Very good cosmesis and minimum psychological trauma. The adjuvant radiation -:Controls Residual microscopic disease. :Eliminates occult multicentric cancer cells from elsewhere in the breast.

BRACHYTHERAPY UNIT AT ARTEMIS

Review of Literatures

Most tumor recurrences after BCT minus radiation are in the tumor bed or in close proximity. Bartelink ----91% recurrence in same quadrant, 56% in the original tumor bed, 27% through out breast. Milan III trial85% relapse in tumor containing area,15% in other quadrant ( same as rates in c/l breast)

Rationale of Boost Radiation

Minimal RT to normal uninvolved breast Gives high dose of radiation to the area with high tumor burden. Reduces local failures and hence distant failures and avoids complications. Deliver homogenous dose: Conform RT to uniformly cover lumpectomy cavity plus 1-2 cm margin
optimize cosmetic result avoid fibrosis and fat necrosis

REVERSE BOOST ?
Boost dose of radiation is given or planned Intra or Per operatively . Followed by whole breast radiation therapy.

Reverse Boost -Advantages

A boost dose of 10-16 Gy is homogenous, It is biologically equivalent to 20 Gy for tumor effect and 30 Gy for late normal tissue effect. Per operative needle implant to the tumor bed. Decreases geographical miss. Avoids second anesthesia. Accurate mapping and targeting of tumor bed immediately after surgery.

Brachytherapy in Breast Carcinoma

A way to deliver localized radiation therapy to the breast using interstitial catheters Renewed interest when performed by Dr. Robert Kuske in New Orleans in 1991 as monotherapy

Our Experience at ARTEMIS

Patient Enrollment

Between July 2008 and June 2009 At ARTEMIS Health Institute Oncology department. 30 patients found suitable for BCS 15/30 patients were found suitable for reverse boost 6/15 patients finally received reverse boost implants.

Criterion for selection

Unifocal tumor of size <3cm N0 or N1 axillary status Histological grade 2 or less. Exclusion criterionTumors in UIQ of the breast Tumors in the axillary tail Invasive lobular carcinomas Carcinoma in situ.

Table 1. Patient Characteristics

HK AGE Menopausal status Tumor Nodes Margins Histology Grade Receptors EBRT Chemo/AE 50 pre T2 N0 negative IDC low positive Yes AE AS 55 post T2 N0 negative IDC low positive No chemo PS 75 post T4 N1 negative IDC low positive Yes AE SS 44 pre T2 N0 IDC interm positive Yes AE PP 46 post T2 N1 IDC interm ER+ve Yes Chemo MG 26 pre T2 N1 negative IDC interm positive Yes AE+Chemo+ Herceptin

negative negative

IDCinfiltrating ductal carcinoma Inter-intermediate grade

Chemo-chemotherapy AE- anti-estrogen

METHOD OF INTRAOPERATIVE IMPLANT

PTV=EXCISED CAVITY +2 cm margin in X axis and 1 cm in Y axis Treated length was 30%> target length for peripheral isodose dip Holes in template were 10mm apart and in equilateral triangle Single and double plane implants done according to tumor size

After implant guiding needles replaced by flexible catheters Simulation with 2 orthogonal rays done next day to define treatment length of each needle Most peripheral source position was 5 mm from skin surface. Max skin dose was 60% of prescribed dose

Dose-12-16 Gy in fractions of 3-4 Gy each, 6 hrs apart Dose prescribed to 10mm from surface of implant First treatment given 48 hrs after lumpectomy Patient discharged the day after removal of catheters in brachytherapy suite

Multiplane catheter Based Dose-12-16 Gy over 4-5 # 6 hours apart

Treatment

Table 2 Treatment Details

NAME HK AS PS Number of catheters/planes 13 double planes 6 single plane 7 single plane Dwell Positions 286 114 257 Volume of implants 70 cc 29.25 cc 44.8 cc Dose prescribed 12Gy in 4fractions 18Gy in 6 fractions 16Gy in 4 fractions 15Gy in 5fractions 15Gy in 5 fractions 12 Gy in 4 fractions EBRT Yes No Yes

SS

13 double plane

196

79.5 cc

Yes

PP

8 single plane

279

73.9 cc

Yes

MG

13 double plane

195

98 cc

yes

Results of Brachytherapy
Hematoma 2/6 patients (33%). 48-72 hrs after removal of implants, needed evacuation. No pain, infection, skin Breakdown or pain requiring strong analgesics

Results Of Brachytherapy

Other methods of reverse Boost

TARGIT (50KV radiation source) Mammosite (interstitial balloon therapy) ELIOT-Electron intraoperative Radiotherapy 3D conformal radiation Salzburg technique9-10 Gy 8Mev electrons delivered directly to the tumor bed after lumpectomy.

Leakage of balloons causing high doses to tissues closer to the source Cannot be used in large or irregular cavities. Dose distribution less homogenous with single seed Infection rate 16%, and telengiectasia >30% Concern about long term morbidities due to high skin dose and compression of normal surrounding tissues.

Mammosite

Intraoperative radiation with electrons or KV X Rays

Limited data of long term and short term effects. Questionable tumor localization. High infection rate. Treatment is completed before final histopathology reports. Operator dependent In TARGIT penetration depth of KV beams to 5-10mm may be insufficient.

Partial breast irradiation

Reduction of the radiation volume to the volume of the primary disease only. APBIDose given faster than the standard once per day. ---Typically given twice per day separated by 6 hrs for normal tissue repair. Short treatment time Overcomes long distance problems Cost effectiveness Low alfa/Beta ratio, so radio biologically effective

PBI-Arguments against

WBI is time tested,well tolerated, good cosmetic outcome. Trials investigating PBI vs. WBI Local Control comparable to WBI EBCTCG meta analysis (Lancet 2005) show small but significant survival advantage in WBI Not all studies report low LRR outside the tumor cavity