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

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

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  1. CyberKnife Radiosurgery in the Treatment of Early and Advanced (Oligo-Metastases) Breast Cancer Sandra Vermeulen, MD Co- Director, Seattle CyberKnife Center Seattle, Wa

  2. Accuray (vendor of Cyberknife) Disclosures

  3. Acceptable cosmesis Local control of disease Minimal treatment complications Breast Conservation Therapy Treatment Objectives

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

  5. 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

  6. External Beam Irradiation

  7. External Beam Coverage of the Breast and Inclusion of Normal Tissues

  8. Decreased time and inconvenience Decreased acute and chronic toxicity Improved radiation therapyunderutilization Advantages of Partial Breast Irradiation over Whole Breast Treatment

  9. Regional Failures within the Breast

  10. 3-D conformal external beam radiotherapy Multi-catheter brachytherapy Balloon catheter brachytherapy Intra-operative Radiotherapy Techniques for Partial Breast Irradiation

  11. Multi-Catheter Brachytherapy

  12. Multi-Catheter Brachytherapy

  13. 3-D Conformal Irradiation Technique

  14. Balloon Catheter Brachytherapy

  15. IORT 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

  16. NSABP Protocol B-39RTOG 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

  17. 3D Conformal External Beam Radiotherapy 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

  18. NSABP Target Volume for 3D-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

  19. Novel Techniques for Partial Breast Irradiation CyberKnife

  20. Approved by the FDA since 2001 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

  21. Advanced interactive robotics Real-time imaging Dynamic automated motion tracking Flexible and accurate linac multiple-beam radiation delivery How is the technology different?

  22. Skull and spine tracking: bony landmarks are tracked 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

  23. Fiducial Tracking Gold seeds 5.0 mm x 0.9-1.2 mm

  24. Respiratory Tracking 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

  25. 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

  26. Cyberknife Demonstration

  27. Cyberknife Beam Profile

  28. Intracraniallesions: 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

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

  30. Primary and Secondary Aims of Study 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

  31. Stage 0, I, II non-lobular 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

  32. Justification of Radiosurgical Dose 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

  33. 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

  34. Cyberknife PBI Treatment Volume

  35. Seattle Cyberknife 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

  36. 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

  37. 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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