Download Accelerated Partial Breast Irradiation (APBI)

Accelerated Partial Breast
Irradiation (APBI)
Michael Zhang (MSIV), Matthew Spraker, MD, PhD
(PGY3)
Faculty Mentor: Janice Kim, MD
University of Washington/Seattle Cancer Care Alliance
Seattle, WA
November 16, 2015
Case Presentation
• 62 year old female underwent annual bilateral
screening mammogram
– A new focal asymmetry in the left breast upper
outer quadrant was demonstrated
• Patient is otherwise asymptomatic
Patient History
• Past Medical History
– Hyperlipidemia
• Past Surgical History
– Tonsillectomy as a child
– C-section in 1984
• Medications
– Atorvastatin
• No known drug allergies
Patient History (con’t)
• Gynecologic History
–
–
–
–
G2P3, 28 years old at first pregnancy
Second pregnancy identical twins
Menarche at 13, natural menopause at 50
OCP use from age 21-27, and hormone replacement
therapy from age 52-54.
• Social History
– Currently working full time as an engineer.
– Never smoker, no current alcohol or drug use, or history of
IV drug use. No prior XRT exposure.
– Strong family support.
• No known family history of malignancy
Physical Exam
• Vitals: HR 62, BP 117/75, RR 13, Temp 98.4F
• General: Well-appearing female, relaxed, alert,
conversational.
• Lymphatics: No palpable cervical, supraclavicular, or axillary
lymphadenopathy bilaterally.
• CV: RRR, no murmurs, rubs, or gallops.
• Resp: CTA B/L.
• Breast: Breasts are symmetrical and appear to be D cup
breasts. There is no visible erythema, edema, nipple
inversion, or discharge. There are no palpable masses.
• Neurologic: CN II-XII grossly intact, no focal neurologic
deficits otherwise noted, sensation grossly intact
throughout, gait normal.
Diagnostic Workup
• Diagnostic left mammogram
– Confirms 13mm irregular mass in the left breast at 1
o’clock, mid-depth.
• Targeted US of left breast
– Re-demonstrates 13mm solid mass in the left breast at 1
o’clock, 30mm from nipple.
• US-guided core needle biopsy
– Invasive ductal carcinoma
– Intermediate grade
– ER/PR positive (Allred 8/8 for both), Her2/neu
amplification negative by FISH analysis.
Multidisciplinary Discussion
• Patient was presented at the multidisciplinary
breast cancer tumor board.
• Presented options for local treatment: simple
mastectomy, lumpectomy/SLNB + WBI, or
lumpectomy/SLNB + accelerated partial breast
irradiation (APBI).
• The patient elected to undergo
lumpectomy/SLNB + APBI using Contura multilumen balloon catheter.
November 16, 2015
Introduction to APBI
• Whole breast irradiation (WBI)
– Standard of care after breast conservation surgery for
early stage breast cancer.
• APBI introduced with possible advantages over
WBI while providing equivalent LC in low risk
patients
– Shortened treatment course
• Typically 5-7 days vs 4-6 weeks
– Decreased radiation dose/toxicity
• Reduced exposure to heart, lung, ribs.
November 16, 2015
Which patients should be
considered for APBI?
• Must be candidates for breast-conserving therapy
– No prior radiotherapy
– No history of collagen vascular diseases
– Not pregnant
• Consensus guidelines from ASTRO in 2009 put
patients into 3 classes
– Suitable
– Cautionary
– Unsuitable
November 16, 2015
ASTRO consensus statement for APBI
Suitable
(Pt meets all criteria)
Cautionary
(Pt meets any criteria)
Unsuitable
(Pt meets any criteria)
Age
≥ 60
50-59
< 50
Tumor Size, T stage
≤ 2 cm, T1
2.1 – 3 cm, T0 or T2
> 3 cm, T3-T4
N stage, surgery
pN0 (SNBx or ALND)
Margins
Negative (≤ 2 mm)
Close (< 2 mm)
Positive
LVSI
No
Limited/focal
Extensive
ER status
Positive
Negative
Centricity
Unicentric
Microscopic multicentricity
Histology
Invasive ductal or
favorable histology
Invasive lobular
EIC or Pure DCIS
Not allowed
≤ 3 cm
Associated LCIS
Allowed
Neoadjuvant Tx
Not allowed
November 16, 2015
pN1-3 or no nodal
surgery
Present
> 3 cm
Received
ASTRO vs. ABS vs. ASBS
Comparison of criteria for approved group
ASTRO “Suitable”
(2009)
ABS (2013)
ASBS (2011)
Age
≥ 60
≥ 50
≥ 45 (IDCA), ≥ 50
(DCIS)
Tumor Size, T stage
≤ 2 cm, T1
≤ 3 cm
≤ 3 cm
N stage, surgery
pN0 (SNBx or ALND)
pN0 (SNBx or ALN
level I/II)
pN0 (SNBx)
Margins
Negative (≤ 2 mm)
Negative microscopic
Negative microscopic
Centricity
Unicentric, clinically
unifocal
Unifocal
LVSI
Not present
Not present
Histology
Invasive ductal or
favorable histo
Any invasive
November 16, 2015
Invasive ductal or DCIS
APBI Methodology
• Multiple methods available
– Brachytherapy
• Multi-catheter interstitial (High, Low, or Pulsed dose rates)
• SAVI
• Balloon catheterization (Mammosite, Contura)
– External beam
• Electrons
• 3D-CRT/IMRT
• Protons
– Single-dose intraoperative radiotherapy (IORT)
• Multi-catheter interstitial brachytherapy has longest
history, but currently data lacking to determine optimal
method of delivering APBI.
November 16, 2015
RTOG 95-17 - Phase II trial
• APBI alone using multi-catheter interstitial brachytherapy
after lumpectomy in early-stage breast cancer.
• 99 patients treated prospectively with HDR or LDR
brachytherapy.
– Eligibility: Stage I/II, unifocal, invasive non-lobular, negative margins,
Tumor ≤3cm, Level I/II ALND with 0-3 positive nodes without ECE.
Modality
HDR
# pts Tumor
Mediancontrol
5-year failure
rates
Survival rates
(Arthur
2008 IJROBP)
tx
f/u
Ipsilat.
Contralat. Regional Mastectomy Disease
br
br
free
free
Overall
66
6.55 yrs
3%
2%
5%
88%
86%
92%
33
7.09 yrs
6%
6%
0%
85%
88%
94%
(34Gy, 10 BID
fxns in 5 days)
LDR
(45Gy in 3.5-6
days)
November 16, 2015
RTOG 95-17 - Phase II trial (cont’d)
• Toxicity and cosmesis (Rabinovitch et al. 2014)
– Skin toxicity at 5 years (% of pts):
• Grade 1-2 (78%), Grade 3 (13%), no G4
•
•
•
•
•
54% - Catheter marks
45% - Fibrosis
45% - Telangiectasias
37% - Dimpling or indentation
15% - Symptomatic fat necrosis (1 req’d surgical excision, no pt req’d mastectomy)
– Patient-reported outcomes after 5 years (% of pts):
•
•
•
•
Breast asymmetry (73%), of which 77% reported a smaller treated breast
Excellent/good cosmesis (66%)
Satisfaction w/ treatment (75%)
Would choose same treatment again (95%)
November 16, 2015
Treatment
• Our patient underwent lumpectomy/SLNB with
Contura maintenance catheter placement intraop
– Invasive ductal carcinoma measuring 7mm
– No associated DCIS
– Surgical resection margins widely negative (>5mm for
all margins)
– ER+, PR+, Her2/neu amplification negative
– SLNBx reviewed intraoperatively 0/2 LNs positive for
disease
• Contra balloon spacer replaced with Contura HDR
brachytherapy unit during CT simulation
Treatment
• CT simulation completed with brachytherapy
device in place. Pt is simulated on breast board
with both arms up.
• Maintenance catheter was removed and Contura
treatment catheter device placed with radioopaque dye to visualize balloon and intraluminal
catheters for treatment planning.
• Treatment device remains in place for 5 days.
• Total dose of 34Gy delivered in BID fractions with
greater than 6 hours of intrafx interval.
Treatment
Five catheter channels connected to HDR after-loader for treatment
November 16, 2015
Treatment Set Up
Catheter aligned to
tattoo to ensure
daily rotational
consistency.
November 16, 2015
Fluoroscopic imaging to ensure set up
performed prior to each daily fraction
Day 1 – Fluoroscopy set up
November 16, 2015
Day 3 – Fluoroscopy set up
References
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American Society of Breast Surgeons, 2011, https://www.breastsurgeons.org/statements/PDF_Statements/APBI.pdf
Arthur, D.W., Winter, K., Kuske, R.R., Bolton, J., Rabinovitch, R., White, J., Hanson, W.F., Wilenzick, R., and McCormick, B.
(2008). A Phase II Trial of Brachytherapy Alone Following Lumpectomy for Select Breast Cancer: tumor control and survival
outcomes of RTOG 95-17. Int. J. Radiat. Oncol. Biol. Phys. 72, 467–473.
Kamrava, M., Kuske, R.R., Anderson, B., Chen, P., Hayes, J., Quiet, C., Wang, P.-C., Veruttipong, D., Snyder, M., and Jeffrey
Demanes, D. (2015). Outcomes of Breast Cancer Patients Treated with Accelerated Partial Breast Irradiation Via
Multicatheter Interstitial Brachytherapy: The Pooled Registry of Multicatheter Interstitial Sites (PROMIS) Experience. Ann.
Surg. Oncol.
Rabinovitch, R., Winter, K., Kuske, R., Bolton, J., Arthur, D., Scroggins, T., Vicini, F., McCormick, B., and White, J. (2014). RTOG
95-17, a Phase II trial to evaluate brachytherapy as the sole method of radiation therapy for Stage I and II breast carcinoma-year-5 toxicity and cosmesis. Brachytherapy 13, 17–22.
Shah, C., Vicini, F., Wazer, D.E., Arthur, D., and Patel, R.R. (2013). The American Brachytherapy Society consensus statement
for accelerated partial breast irradiation. Brachytherapy 12, 267–277.
Smith, B.D., Arthur, D.W., Buchholz, T.A., Haffty, B.G., Hahn, C.A., Hardenbergh, P.H., Julian, T.B., Marks, L.B., Todor, D.A.,
Vicini, F.A., et al. (2009). Accelerated partial breast irradiation consensus statement from the American Society for Radiation
Oncology (ASTRO). Int. J. Radiat. Oncol. Biol. Phys. 74, 987–1001.
Please provide feedback regarding this case or other ARROcases to [email protected]
November 16, 2015