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CyberKnife Radiosurgery in the Treatment of Early and

Advanced (Oligo-Metastases) Breast Cancer

Sandra Vermeulen, MDCo- Director,

Seattle CyberKnife CenterSeattle, Wa


Disclosures

Accuray (vendor of Cyberknife)


Breast Conservation Therapy Treatment Objectives

• Acceptable cosmesis

• Local control of disease

• Minimal treatment complications


In 2000 the National Cancer Data Base reported that only 50% of eligible

candidates received conservative surgery followed by radiation therapy


Prospective Randomized TrialsBCS + RT vs MRM

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


External Beam Irradiation


External Beam Coverage of the Breast and Inclusion of

Normal Tissues


Advantages of Partial Breast Irradiation over Whole Breast

Treatment

• Decreased time and inconvenience

• Decreased acute and chronic toxicity

• Improved radiation therapy underutilization


Regional Failures within the Breast

Trial CS Alone CS + RT

NSABP 2.7 17/636 3.8 24/629

Ontario 3.5 15/421 0.9 4/416

Milan 2.8 8/280 0.6 2/299

Finland 5.5 4/72 5.0 4/80

Sweden 1.5 3/194 0.5 1/187

Range (%) 1.5-5.5 0.5-5.0


Techniques for Partial Breast Irradiation

• 3-D conformal external beam radiotherapy

• Multi-catheter brachytherapy• Balloon catheter brachytherapy• Intra-operative Radiotherapy


Multi-Catheter Brachytherapy


3-D Conformal Irradiation Technique


Balloon Catheter Brachytherapy


IORTVeronesi 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


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


NSABP Dose Prescription

• 3D Conformal External Beam Radiotherapy38.00 Gy total dose at 3.85 Gy per fraction delivered twice

daily in 10 fractions over 5 treatment days

• Multi-Catheter and Balloon catheter Brachytherapy34 Gy total dose at 3.4 Gy per fraction delivered twice

daily in 10 fractions over 5 treatment days


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 motionpatient motion and variability of

treatment set-up


Novel Techniques for Partial Breast Irradiation

CyberKnife


CyberKnife

• 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


How is the technology different?

• Advanced interactive robotics

• Real-time imaging

• Dynamic automated motion tracking

• Flexible and accurate linac multiple-beam radiation delivery


Methods for tracking motion

• 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


Fiducial Tracking

Gold seeds

5.0 mm x 0.9-1.2 mm


Respiratory Tracking

Beam Off

Beam OffBeam On

Beam On

Treatment Field

1.1. 2.2.

3.3. 4.4.

Gating SynchronyTM

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

= Over-treated healthy tissue


Accuracy• 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


Cyberknife Demonstration


Cyberknife Beam Profile


Indications for Cyberknife

• Intracranial lesions: 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


A phase II Study of CyberKnife Radiosurgery delivered to the

Partial Breast for Women with Stage 0, I, II Breast Cancer

Seattle CyberKnife


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


Patient Eligibility

• 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


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


Partial Breast Planning for CyberKnife

• 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


Cyberknife PBI Treatment Volume


Cyberknife Radiosurgery for Early Breast Cancer: a pilot investigation

to determine the feasibility of Synchrony imaging and fiducial

identification for motion tracking

Seattle Cyberknife

Fresno Community Regional Medical Center


Protocol Objectives

• 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


Seattle CyberKnife Summary• 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

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