DESCRIPCIÓN DE TÉCNICAS DE

BRAQUITERAPIA EMPLEADAS EN A.P.B.I

Dr. Jose Luis Guinot Rodríguez

Asimetría por RT externa CSE MD APBI intersticial LICS MI

Tamaño tumor/mama

Selección de pacientes Un nuevo paradigma en cáncer de mama precoz:

La irradiación parcial de mama

Evolución de las técnicas APBI

1982

•RT Conven-cional

1987

•BT intersticial multicateter

… …

1997

•RT 3D conformada

1998

• IORT 50kV TARGIT

1999

• IORT ELIOT

2000

• Intracavitaria MammoSite

2004

• IMRT

•Tomoterapia

•Pd103seeds

2007

•Protones

2008

• Intracavitaria hibridos

…

Irradiación parcial acelerada de mama APBI: accelerated partial breast irradiation

DIFERENTES TÉCNICAS

DIFERENTES RESULTADOS Intraoperatoria Intracavitaria

Intersticial

INTRAOPERATORIA IORT

Sesión única - Electrones (ELIOT) - Rayos X 50 kV (TARGIT)

Técnicas APBI

European Institute of Oncology (EIO) Milán 48-75 años T hasta 2,5cm. RECAIDA MAMA 651 pacientes 21 Gy dosis única 4,4% 654 pacientes RT 60 Gy 0,4%

APBI intraoperatoria IORT con electrones ELIOT

2013

Veronesi U et al. Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial. Lancet Oncol 2013;13:1269-77

1822 pacientes (seguimiento medio 3,5 años)

ASTRO CONSENSUS Suitable Cautionary Unsuitable

Pacientes 294 691 812

Rec local a 5 años 1,5% 4,4% 8,8%

GEC-ESTRO recomendaciones

Buenos candidatos Posible contraindicado

Pacientes 573 468 767

Rec local a 5 años 1,9% 7,4% 7.7%

Resultados ELIOT Milán

Leonardi. MC. Int J Radiat Oncol Biol Phys 2012 jul

Radiother Oncol 2013 Jan

APBI intraoperatoria IORT con electrones ELIOT

En bajo riesgo da buenos resultados, pero no se conocen los factores de riesgo en el momento del tratamiento

Dosis única 20 Gy a la superficie del aplicador

APBI intraoperatoria IORT con RX 50 kV TARGIT (Targeted intraoperative)

McCready DR, Henderson MA. Targeted Intraoperative Radiation Therapy (TARGIT). In: Klimberg VS, editor. Atlas of Breast Surgical Techniques. Philadelphia: Saunders Elsevier, 2010. Series Editors: Townsend C, Evers M.

Intraoperative APBI IORT 50 kV X-Rays. TARGIT (Targeted intraoperative)

Vaidya JS et al. Risk adapted targeted intra-operative radiotherapy vs WBRT 5-year local control and OS from the TARGIT-A randomised trial. Lancet 2014; 383:603-13

1721 TARGIT (15% recibieron WBI) 1730 WBI

-Permite añadir RT con f. de riesgo -Las recaidas se deben a una mala localizacion del lecho (trat postop).

3.3% vs 1.3% Perioperative

Postoperative

TARGIT (Targeted intraoperative) Resultados con IntraBeam

2014

BRAQUITERAPIA INTRACAVITARIA

- MammoSite - Contura - SAVI - Electronic BT: Xoft Axxent

Intracavitary single-lumen catheter balloon: Mammosite

Intracavitary multilumen balloon: Contura; MammoSite multilumen

Intracavitary multilumen cage-like: Clear-Path SAVI Strut Adjusted Volume Implant

Xoft, Inc. (Sunnyvale, CA, USA). FDA 2006 Axxent® electronic brachytherapy system • RX 50 kV • Balón con un solo catéter, incluye drenaje • Balón radiolúcido, mejora la visibilidad en la

radiografia y TAC • No requiere contraste

Intracavitary single catheter balloon: Axxent

Implantable accelerated partial

breast irradiation (IAPBI) by patient age from 2000 through 2007

Abbott AM, Habermann EB, Tuttle TM. Trends in the use of implantable accelerated partial breast irradiation therapy for early stage breast cancer in the United States. Cancer 2011; 117:3305-3310.

• Hologic estimates that >50,000 women to date have been treated with MammoSite

• The rapid and widespread adoption of IAPBI is concerning, because large multicenter randomized controlled trials have not yet demonstrated the long-term effectiveness of IAPBI compared with WBRT

Trends in the use of catheter balloon: MammoSite

© Manuel Algara Smith GI, Xu Y, Buchholz TA, et al.

JAMA 2012;307:1827-37

•Retrospective study •APBI hazard ratio 2.2 (95%CI) vs mastectomy •Balloon technique

APBI intracavitaria con mammosite 2012

EN CONTRA

• Gradiente

• Inhomogeneidad

• Dosis alta a piel o costillas

• Coste

A FAVOR

• Sencillez

• Colaboración con cirujano

• Implante perioperatorio

• Visualización de lecho

APBI intracavitaria evolución a multicanal

BRAQUITERAPIA INTERSTICIAL

POSTOPERATORIA

- Tubos plásticos - Cavidad abierta - Cavidad cerrada

- Agujas

Técnicas APBI

ICO BARCELONA technique : US-guided implant.

CAVIDAD

ABIERTA

Technique Budapest: CT guided implant. Open cavity

Technique Budapest: CT guided implant. Open cavity

Technique Erlangen: X-Rays clips-guided implant. Closed cavity

CAVIDAD CERRADA

Technique IVO: US-guided implant. Closed cavity

Chest wall

Distance from bottom needle to the chest wall

Number of planes

Clips are not visible with US but can be projected on the skin (previous CT)

LIMITACIONES PARA DEFINIR EL CTV

LECHO QUIRÚRGICO NO ES IGUAL

A LECHO TUMORAL

– Radiation is only given to the cavity

– No margin can be added

– The cavity is modified by the surgeon to create an sphere

– Skin and chest wall can receive a high dose.

– Intraoperative irradiation misses information about margins

– There is a “missed CTV”

Missed CTV

Bartelink H. Radiat Oncol August 2012

Limitations of endocavitary radiation

Limitations of CLIPS

– Clips are useful to know where the surgeon arrived, but they have no a clear correlation with the tumour margins

– There are “irrelevant clips”

– Displacement of the clips along time

Decrease in tumor bed volume as defined by clips. Hepel JT et al

Clips at the beginning of WBI Clips after WBI, for the boost

• The main problem is to use an image technique (CT) to look for a tumour bed to be irradiated, when no GTV can be seen • There will always be differences between observers!!! • Surgical scar is useful but what we see is only the manipulated area, not the tumour bed.

CAVITY VISUALIZATION SCORE (CVS) Landis et al. IJRadiat Oncol Biol Phys 2007. 67:5 Van Mourik AM et al. Multiinstitutional study on target volume delineation variation in breast radiotherapy in the presence of guidelines. Radiother Oncol 2010; 94:286–291

Limitations of CT images

DEFINITION OF CTV 2015

DEFINITION OF CTV

Guidelines for target definition after breast conserving open cavity surgery

2016

BRAQUITERAPIA INTERSTICIAL

PERIOPERATORIA

- Tubos plásticos

Técnicas APBI

Technique IVO: Perioperative implant. Closed cavity

Technique IVO: Perioperative implant. Closed cavity

Technique IVO: Perioperative implant. Closed cavity

Planning sheet

Constraints: - D90 CTV > 100%

- DNR: <0.35 (V150/V100)

-Skin dose <70%

Planning CT scan 1-2 days later

-cut plastic tubes at the same distance -Draw marks on the plastic tubes -mark skin scar and nipple

Irrelevant clip

Clip marking the bottom of the cavity

Relevance of clips placement

ETB

clip

margin

CTV

clips ETB

CTV

A small area above the guide-tube was

drawn with central clips if present.

The resulting volume was adjusted to cover the lateral

plastic tubes with a margin of a few mm to obtain the CTV.

Dosis 4 Gy dos veces al día x 8 sesiones

Dose per fraction

Number of

fractions

Total time days

Mean dose to

lung

Maximum dose to

lung

Maximum dose to heart

Standard EBRT

2Gy 25 33-35 11.4Gy 51.75 Gy 49.75Gy

Hypofrac-tionated

EBRT 2.67Gy 16 22 6.41Gy 43.7Gy 42Gy

POBT APBI

4Gy 8 4-5 1.2Gy 14Gy 8Gy

Guinot JL, Samper J, Santamaria P, et al. Doses to organs-at-risk decrease dramatically with

multicatheter breast brachytherapy. Clin Transl Oncol 2015 suppl June.

Dosis a órganos de riesgo.

Comparación de técnicas de RT.

ESTRO-ACROP guideline: Interstitial Multi-Catheter

Breast Brachytherapy as Accelerated Partial Breast

Irradiation Alone or as Boost - GEC-ESTRO Breast

Cancer Working Group Practical Recommendations Version 07 06 2017

Vratislav Strnad1, Tibor Major2, Csaba Polgar2, Michael Lotter1, Jose-Luis

Guinot3, Cristina Gutierrez-Migueles4, Razvan Gallalae5, Erik van

Limbergen6, Benjamin Guix7, Peter Niehoff8, Cristina Lössl9, Jean-

Michel Hannoun-Levi10

La irradiación parcial de mama APBI: • con intraoperatoria (ELIOT) tiene más recaídas por

imposibilidad de seleccionar factores de riesgo • Con intraoperatoria (TARGIT) se puede compensar

con RT externa en casos de riesgo. Debe hacerse perioperatoria.

• Con balón (mammoSite) tiene más complicaciones • Con intracavitarias multicateter pendiente evolución

• Con RT externa parcial 15 x 267 es eficaz (IMPORT-

LOW • Con RT externa IMRT aún pendiente

CONCLUSIONES

- Nuevo paradigma: En cáncer de mama de bajo riesgo con >50 años sin ganglios, (T<3cm, CIE-, IVL-, N0, borde >2mm) no está indicado irradiar toda la mama

- APBI con multicatéter es igual a RT de mama,

con menos dosis a OAR. - Cavidad abierta - Cavidad cerrada - Perioperatoria

- Elegir técnica según cada caso y experiencia

CONCLUSIONES