Cyberknife radiosurgery in the treatment of early and advanced oligo metastases breast cancer
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CyberKnife Radiosurgery in the Treatment of Early and Advanced (Oligo-Metastases) Breast Cancer . Sandra Vermeulen, MD Co- Director, Seattle CyberKnife Center Seattle, Wa. Accuray (vendor of Cyberknife). Disclosures. Acceptable cosmesis Local control of disease

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Cyberknife radiosurgery in the treatment of early and advanced oligo metastases breast cancer l.jpg

CyberKnife Radiosurgery in the Treatment of Early and Advanced (Oligo-Metastases) Breast Cancer

Sandra Vermeulen, MD

Co- Director,

Seattle CyberKnife Center

Seattle, Wa


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Accuray (vendor of Cyberknife) Advanced (Oligo-Metastases) Breast Cancer

Disclosures


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Acceptable cosmesis Advanced (Oligo-Metastases) Breast Cancer

Local control of disease

Minimal treatment complications

Breast Conservation Therapy Treatment Objectives


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In 2000 the National Cancer Data Base reported that only 50% of eligible candidates received conservative surgery followed by radiation therapy


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Trial LR % Survival % F/U

BCT vs MRM BCT vs MRM Years

NSABP 14 v 10 47 v 46 20

Milan 9 v 2 59 v 59 20

Prospective Randomized TrialsBCS + RT vs MRM




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Decreased time and inconvenience Tissues

Decreased acute and chronic toxicity

Improved radiation therapyunderutilization

Advantages of Partial Breast Irradiation over Whole Breast Treatment



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3-D conformal external beam radiotherapy Tissues

Multi-catheter brachytherapy

Balloon catheter brachytherapy

Intra-operative Radiotherapy

Techniques for Partial Breast Irradiation






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IORT Tissues

Veronesi et al: A preliminary report of IORT in limited stage breast cancers that are conservatively treated. Eur J Cancer. 2001 Nov;37(17):2178-83

Mobile linear accelerator

3-9 Mev eb

10-21 Gy in 103 patient

No complications


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NSABP Protocol B-39 TissuesRTOG Protocol 0413

A randomized Phase III Study of Conventional Whole Breast Irradiation vs Partial Breast Irradiation for Women with Stage 0, I, II Breast Cancer


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3D Conformal External Beam Radiotherapy Tissues

38.00 Gy total dose at 3.85 Gy per fraction delivered twice daily in 10 fractions over 5 treatment days

Multi-Catheter and Balloon catheter Brachytherapy

34 Gy total dose at 3.4 Gy per fraction delivered twice daily in 10 fractions over 5 treatment days

NSABP Dose Prescription


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NSABP Target Volume for Tissues3D-CRT

The CTV is defined by expanding the excision cavity volume by 15 mm. The PTV includes a 10 mm expansion of the CTV to compensate for patient motion and variability of treatment set-up



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Approved by the FDA since 2001 Tissues

Nearly 30,000 patients treated worldwide

More than 200 peer review papers have been published

More than 80 hospitals and medical centers provide CyberKnife technology

CyberKnife


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Advanced interactive robotics Tissues

Real-time imaging

Dynamic automated motion tracking

Flexible and accurate linac multiple-beam radiation delivery

How is the technology different?


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Skull and spine tracking: bony landmarks are tracked Tissues

Fiducial tracking: radio-opaque marker are placed near soft tissue targets and tracked

Respiratory tracking (Synchrony): with respiration, LED’s on the exterior of the patient are correlated with the movement of the target/tumor and fiducials

Methods for tracking motion


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Fiducial Tracking Tissues

Gold seeds

5.0 mm x 0.9-1.2 mm


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Respiratory Tracking Tissues

SynchronyTM

Gating

Treatment Field

= Over-treated healthy tissue

1.

2.

Beam Off

Beam On

3.

4.

Beam On

Beam Off

Treatment beam is turned on and off as tumor enters and exits a static treatment field

Dynamic treatment field follows the tumor while the treatment beam is turned on


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When used properly, Synchrony™ provides a degree of accuracy of better than 1.5mm

Allows reduced planning margins for lesions that move with respiration

Gating and breath holding require margins of 5-10mm to compensate for setup and targeting uncertainty

Accuracy


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Cyberknife Demonstration accuracy of better than 1.5mm


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Cyberknife Beam Profile accuracy of better than 1.5mm


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Intracranial accuracy of better than 1.5mmlesions: single fraction, or fractionated

Head and neck:

Nasopharynx & base of skull, primary or recurrent

Other sites, as boost following conventional RT, or recurrent

Spine: where surgery indicated but not feasible, and conventional RT less effective or not possible

Lung: where surgery indicated but not feasible

Liver: where surgery indicated but not feasible

Pancreas: unresectable but localized tumors

Kidney: where surgery indicated but not feasible

Previously irradiated tumors: retreatment w/ conventional RT not possible, for severe symptoms, Karnofsky > 40

Indications for Cyberknife


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A phase II Study of CyberKnife Radiosurgery delivered to the Partial Breast for Women with Stage 0, I, II Breast Cancer

Seattle CyberKnife


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Primary and Secondary Aims of Study Partial Breast for Women with Stage 0, I, II Breast Cancer

This study will evaluate the technical feasibility of PBI with the CyberKnife as well as evaluate QOL issues that relate to treatment side-effects, cosmetic outcomes and patient convenience


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Stage 0, I, II non-lobular breast cancer Partial Breast for Women with Stage 0, I, II Breast Cancer

Cancer must be ≤ 3 cm

Surgical treatment must be a lumpectomy

Margins must be > 2mm for both DCIS and invasive disease

Negative sentinel Lymph node(s) or an axillary dissection

Lumpectomy cavity must be clearly delineated

Patient Eligibility


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Justification of Radiosurgical Dose Partial Breast for Women with Stage 0, I, II Breast Cancer

By applying the linear-quadratic cell survival model with an alpha-beta ratio of 4, a dose of 30 Gy given in 5 stages of 6 Gy between 5 to 10 days is radiobiologically equivalent in tumor control and late breast tissue complications as the whole breast doses used by NSABP


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The CTV is the excision rim plus a 10 mm margin in all directions

The PTV is defined as the CTV plus a 5mm margin

The dose is will be delivered to the 70 - 85% isodose prescription line

Partial Breast Planning for CyberKnife



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Seattle Cyberknife directions

Fresno Community Regional Medical Center

Cyberknife Radiosurgery for Early Breast Cancer: a pilot investigation to determine the feasibility of Synchrony imaging and fiducial identification for motion tracking


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To determine if there is sufficient geometric stability of gold markers in the breast for Synchrony motion tracking

To determine the optimal patient treatment position for Synchrony motion tracking

Protocol Objectives


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Greater than 140 sites treated including primary tumors of the lung, brain, prostate and

metastases to the lung, liver, brain and bone

June 2007 to begin a breast pilot to determine the feasibility of Synchrony motion tracking

January 2008 planned open enrollment for a multi-institutional PBI protocol using Cyberknife

Seattle CyberKnife Summary


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