targit surgical aspects in iort - dansk brystkirurgisk...
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Targit
Surgical aspects in IORT
Niels Bentzon
Dept. of Breast Surgery
Herlev-Gentofte Hospital
University of Copenhagen
DK-2730 Herlev
Why change?
”If we stop improving,
we stop being good”
OLIVER CROMWELL,
1599-1658
Shanafelt TD, Gradishar WJ, Kosty M, et al.
Burnout and career satisfaction among US oncologists.
J Clin Oncol. 2014;32:678-686.
44.7% exhibited one or more
features of burnout, including
emotional exhaustion and
depersonalization.
The best predictor of burnout was
the number of hours spent in direct
patient contact, direct patient care.
+ Diversity:
Teaching
Supervising
Writing
Doing trials
Why change – and what to improve?
• Reduce morbidity?
• Cosmetic result?
• Socioeconomic and logistic reasons:
– EBRT for 5-6 weeks
• Unpractical
• Expensive
• Ressource-demanding
• Operating strategy depending on geography
•“Can you come for radiotherapy every day for 4-6
weeks?”
•YES
•we can
conserve your
breast
•NO
•we need to do
a mastectomy
Breast Clinic,
Sir Charles Gairdner Hospital,
Perth, Australia
Distance OR of receiving BCS
< 10 miles 1
15-20 miles 0.76
> 40 miles 0.55
Travel Distance to Radiation Therapy and Receipt of Radiotherapy
Following Breast-Conserving Surgery
Athas WF et al. JNCI J Natl Cancer Inst (2000) 92 (3): 269-271.
≥ 100 miles distance:
35 % have a breast conserving op.
42% receive radiation therapy
following BCS
Different outcome after EBRT
1 2
Mb. Paget + IDC dxt.
Conus-excision + SN EBRT +
reconstruction of NAC + lipofilling
Stage I IDC
Lumpectomy + 25 x 2 Gy EBRT
Morbidity related to external radiation therapy
• Edema
• Impaired mobility
• Brachial plexus damage
• Telangiectasies
• Change in breast shape
• Subcutaneous fibrosis
• Fracture of the ribs
• Pneumonitis
• Lung fibrosis
• Ischemic heart disease
• Pain
• Sarcoma
The importance of not missing the target
Cancer 2003 Feb 5;97(4):905-9.
Intraoperative radiation therapy, 1905
Billede fra mobetron foredrag
Georges Chicotot
First attempt of treating
breast cancer with X-rays
1907
TARGIT protocols
• Targit A: ”IORT vs. EBRT”
• Targit B: ”Boost”
• Targit C: ”Baloon”
• Targit D: ”DCIS”
• Targit E: ”Elderly”
Jan
2012
TARGIT- A in DK
• IORT was delivered at a secundary procedure
– Advantages:
• Safe inclusion criteria
• Easy planning
– Disadvantages:
• Delay
• Repeated procedure after 2 - 4 w
IORT post pathology
Reopening of the lumpectomy cavity
Preparation of ”collar”
Measuring the cavity
Testing of applicator size
Purse string suture
Sutures in skin flaps
Applicator around the radiation device
Sterile plastic bag
Wet gauze around the neck
of the applicator
No lead in the walls
First patient in Scandinavia
Jyllands Posten 22.04.2007 Dagens medicin 26.04.2007
Preoperative photo
Fie billede
Postoperative photo
Postoperative photo
After lumpectomy + SN + IORT
BCS + IORT in a pt. with an implant 3 & 12 months postop.
Possible ”off-label patients”
• Augmentation prosthesis
• High age
• Previous radiation field
• Concomitant disease
– Systemic
– Heart-
– Lung-
– Extreme obesity (large, fatty breasts)
• Photo each year 0-5 yrs.
• BCCT.core
• Excellent + Good (EG) vs. Fair + Poor (FP)
• OR 2,1 in favour of IORT
• Conclusion:
– IORT leads to a better cosmetic outcome than EBRT
Complications
• Acute
• Erythema
• Impaired wound
healing
• Fistula
• Infection / mastitis
• Seroma
• Cronical
• Erythema
• Fibrosis
• Hyperpigmentation
• Mastitis
• Seroma
• Breast-edema
Complications, Targit A
Hematoma and seroma requiring > 3 aspirations or surgery
Complications, Targit A
Wound infection requiring IV antibiotics or surgery
Complications, Targit A
Skin breakdown or delayed wound healing
Complications, Targit A
Readmission for complications
Tecnical problems
1. Intrabeam stops during treatment
2. Intrabeam delivered wrong dose: 7 pts. treated with a 20% overdose
radiation deeper into the tissue
14 d
7 months 9 months
Skin damage
5 months
TARGIT protocols
• Targit A: ”IORT vs. EBRT”
• Targit B: ”Boost”
• Targit C: ”Baloon”
• Targit D: ”DCIS”
• Targit E: ”Elderly”
Inclusion criteria Targit E
• Tumor ≤ 20 mm
• Unifocal
• Women ≥ 60 år
• No kemoterapi
• ER +
• HER2 negative
• Node negative
• Non-lobular carcinoma
• No EIC nor lymphovascular invasion
≥ 60 years
Invasive ductal carcinoma
< 2 cm
N0 and M0
No risc factors:
•no multifocality/multicentricity
•no EIC (biopsy)
•no lymfovascular invasion (biopsy)
Risc factors at final PAD:
tumour > 3,5 cm
other histological type
Free margins < 2 mm
Lymphovascular invasion
Node +
Multifocality/multicentricity/EIC
No more RT
+ WBRT 46 Gy
(pN1 50 Gy, > pN2 50 Gy incl. lymph node areas)
BCS + SN
IORT 20 Gy
No risc factors
TARGIT E: IORT immediately after lumpectomy + SN
10 yrs. follow-up
• Clinical mammography at
1½, 3½, 5, 7 and 9 yrs.
• Quality of life yearly (EORTC QLQ
BR 23 and C 30)
• Photo at 1.- 5.- yrs. visit.
Radiation in the operation theatre
02468
10121416
-1 1 3 5
mik
ro-S
iev
ert
Patientnummer
I Radiation behind leadshield at distance 1,4 m
Bag skærm MW
Bag skærm UW
0
200
400
600
800
1000
1200
1400
-1 1 3 5
mik
ro-S
iev
ert
Patientnummer
II Radiation at d = 2,5 m from the left side
Position 2 MW
Position 2 UW
0
500
1000
1500
2000
2500
3000
3500
0 1 2 3 4 5
mik
ro-S
iev
ert
Patientnummer
III Radiation at d = 1,5 m oblique fr. foot left side
Position 3 MW
Position 3 UW
0
200
400
600
800
1000
1200
0 1 2 3 4 5
mik
ro-S
iev
ert
Patientnummer
IV Radiation at d = 2,6 m from foot right side
Position 4 MW
Position 4 UW
Bentzon T 2013
Mean reduction of radiation by wolfram plates: 7.5 times
• UW = Without Wolfram plates
• MW = With the Wolfram plates places in position
Bentzon T. 2013
IORT, of course
Thank You
helmer@danskjävlar.dk
Herlev Hospital
Rigshospitalet