Partial Breast Irradiation with Brachytherapy: The Experience ......2014/05/09 · • Dosimetry: modified Paris System (85% MCD) • Skin and ribs < 70% DP Institut Català d’Oncologia

Institut Català d’Oncologia Brachytherapy Unit

Partial Breast Irradiation with Brachytherapy: The Experience of the Institut

Català d’Oncologia

Dr. Cristina Gutiérrez Barcelona, Spain

Institut Català d’Oncologia

Estadísticos Año primer tratamiento N Válidos 12336

Perdidos 0

Año primer tratamiento

Frecuencia Porcentaje Porcentaje

válido Porcentaje acumulado

Válidos 1989 143 1,2 1,2 1,2 1990 346 2,8 2,8 4,0 1991 298 2,4 2,4 6,4 1992 412 3,3 3,3 9,7 1993 398 3,2 3,2 12,9 1994 487 3,9 3,9 16,9 1995 511 4,1 4,1 21,0 1996 482 3,9 3,9 24,9 1997 572 4,6 4,6 29,6 1998 779 6,3 6,3 35,9 1999 717 5,8 5,8 41,7 2000 486 3,9 3,9 45,6 2001 473 3,8 3,8 49,5 2002 573 4,6 4,6 54,1 2003 522 4,2 4,2 58,4 2004 493 4,0 4,0 62,4 2005 576 4,7 4,7 67,0 2006 466 3,8 3,8 70,8 2007 518 4,2 4,2 75,0 2008 459 3,7 3,7 78,7 2009 489 4,0 4,0 82,7 2010 512 4,2 4,2 86,8 2011 507 4,1 4,1 90,9 2012 538 4,4 4,4 95,3 2013 579 4,7 4,7 100,0 Total 12336 100,0 100,0


Estadísticos Año de tratamiento N Válidos 15688

Perdidos 0

Año de tratamiento



Válidos 1989 145 ,9 ,9 ,9 1990 393 2,5 2,5 3,4 1991 319 2,0 2,0 5,5 1992 450 2,9 2,9 8,3 1993 452 2,9 2,9 11,2 1994 540 3,4 3,4 14,7 1995 549 3,5 3,5 18,2 1996 533 3,4 3,4 21,6 1997 627 4,0 4,0 25,5 1998 854 5,4 5,4 31,0 1999 772 4,9 4,9 35,9 2000 528 3,4 3,4 39,3 2001 521 3,3 3,3 42,6 2002 728 4,6 4,6 47,2 2003 667 4,3 4,3 51,5 2004 633 4,0 4,0 55,5 2005 720 4,6 4,6 60,1 2006 590 3,8 3,8 63,9 2007 684 4,4 4,4 68,2 2008 726 4,6 4,6 72,9 2009 772 4,9 4,9 77,8 2010 740 4,7 4,7 82,5 2011 744 4,7 4,7 87,2 2012 888 5,7 5,7 92,9 2013 1113 7,1 7,1 100,0 Total 15688 100,0 100,0


Año de tratamiento



Válidos 1989 38 ,9 ,9 ,9 1990 117 2,7 2,7 3,5 1991 130 3,0 3,0 6,5 1992 169 3,8 3,8 10,3 1993 166 3,8 3,8 14,1 1994 240 5,5 5,5 19,5 1995 257 5,8 5,8 25,4 1996 258 5,9 5,9 31,2 1997 299 6,8 6,8 38,0 1998 443 10,1 10,1 48,1 1999 363 8,2 8,2 56,3 2000 218 5,0 5,0 61,3 2001 176 4,0 4,0 65,3 2002 209 4,7 4,7 70,0 2003 163 3,7 3,7 73,7 2004 202 4,6 4,6 78,3 2005 223 5,1 5,1 83,4 2006 85 1,9 1,9 85,3 2007 69 1,6 1,6 86,9 2008 39 ,9 ,9 87,8 2009 98 2,2 2,2 90,0 2010 95 2,2 2,2 92,2 2011 87 2,0 2,0 94,1 2012 128 2,9 2,9 97,0 2013 130 3,0 3,0 100,0 Total 4402 100,0 100,0

Number of breast implants


Estadísticos Año de tratamiento N Válidos 4402

Perdidos 0


Partial Breast Irradiation

• In our department 185 patients have been treated between february 2004 and april 2014

• 43 in a phase II trial • 27 patients were included in the European

randomised phase III trial (54 included) • 115 out of trial (“safe group”)

– 40 intraoperative • In 17 cases for local relapse as a 2nd conservative

procedure


Interstitial PBI Technique

• 6 F Plastic tubes for HDR “comfort” • Insertion ultrasound-guided or during

tumorectomy • When postoperative, CT dosimetry with

contrast in the surgical bed


Ultrasound-guided


Ultrasound-guided









Institut Català d’Oncologia Unidad de Braquiterapia

Intraoperative BCT Technique

• Plastic 6 F tubes “comfort”. • Inserted during tumorectomy:

– Peroperative pathology: free margins – Negative sentinel node

• Day +1 prepare tubes and CT-dosimetry • Start treatment 3-5 days after surgery


Intraoperative BT


Intraoperative BT


Intraoperative BT


Intraoperative BT


Intraoperative BT

Brachytherapy Unit


Intraoperative BT

Brachytherapy Unit


PBI: Dose and fractionation

• Phase II Trial: 10 fractions of 3.4 Gy • European Phase III trial: 8 fractions of 4 Gy • B.i.d, separated at least 6 hours






Partial Breast Irradiation Dosimetry

• TC with slices every 2 mm • PTV = seroma + 1-2 cm margin (>0.5 cm

of skin and ribs) • Dosimetry: modified Paris System (85%

MCD) • Skin and ribs < 70% DP


PULMÓN

PTV

PIEL

PARED COSTAL

DOSIS

CLIP

Interstitial BT

Brachytherapy Unit


1

6

7 13

14 18

Catheter distribution

Brachytherapy Unit


Implant reconstruction in 3 planes

Brachytherapy Unit


3D Distribution and clips

Brachytherapy Unit


3D Distribution and clips

Brachytherapy Unit


PBI: dosimetric constraints

• DNR (Dose-Nonuniformity Ratio) < 0.35 • CI (Coverage Index): We must try that

100% dose covers > 90% PTV (CI>0.9) • DHI (Relative Dose Homogeneity Index):

Percentage of PTV that receives a dose between 100% and 150% of the Dref.

• COIN (Conformal index). GOOD=1 BAD=0





























Partial Breast Irradiation: our results

• 3 local relapses out of 185 • 2 contralateral • 3 bone M1 • 1 bone M1 from a secondary lung cancer


Local control in months


Local Control with breast conserving therapy at ICO

(625 pac T1, 50Gy+boost 75%BQT)

0 5 1 0 1 5

0.0

0.2

0.4

0.6

0.8

1.0

CEG-ESTRO-ABS-GLAC, Barcelona mayo de 2004. F Moreno, et al. Int J Radiat Oncol biol Phys 48(3): 757-765, 2000.


Cosmesis


Partial Breast Irradiation Conclusion

• Our local control is good (local relapse 1.6%).

• Our local control rate is the same that with our series of BCT

• We still have to analyze carefully our cosmetic results

• We are waiting for the results of the european Phase III trial


Our results comparing intraoperative BT vs postoperative

Intraoperative BT

• 40 patients • 0 relapses • 2 intercurrent deaths • 5 mastitis

Postoperative BT

• 145 patients • 3 local relapses

Brachytherapy Unit


Interstitial Intraoperative BT Comments

• Advantages: – The tubes are optimally inserted covering the tumor bed – The total treatment time is shortened to 4 days (APBI) – Mínimum interval between surgery and RT – Save money because avoid second procedure

• Disadvanteges:

– Time-consuming for the Radiotherapist – That is why IBT is not routinelly performed as boost – Any surprise with the definitive pathologic report – We have a higher rate of mastitis (reirradiations)


BT as a second conservative procedure

• European study: GEC-ESTRO BCWG Phase II trial for second breast conservative treatment (Jean-Michel Hannoun-Levi, Niza)

• Inclusion criteria: – ClinicTm < 3 cm or Pathol < 3.5 cm – Any histology, grade, receptors, DCIS, LVI – Free margins – Unifocality, nodes 0-3, no M1 – > 1 year after end of RT – Intraoperative or postop < 42 days


www.iconcologia.net Institut Català d’Oncologia

ICO l’Hospitalet Hospital Duran i Reynals Gran Via de l’Hospitalet, 199-203 08907 l’Hospitalet de Llobregat

ICO Badalona Hospital Germans Trias i Pujol Ctra. del Canyet s/n 08916 Badalona

ICO Girona Hospital Doctor Trueta Av. França s/n 17007 Girona

Documents

Partial Breast Irradiation with Brachytherapy: The Experience ......2014/05/09 · • Dosimetry: modified Paris System (85% MCD) • Skin and ribs < 70% DP Institut Català d’Oncologia