Long Term Radiation Side Effects in the Treatment of Early Breast Cancer

1
Long Term Radiation Side Effects in the
Treatment of Early Breast Cancer Dr. Sandra
Vermeulen, M.D. Swedish Cancer Institute Northwest
Hospital Gamma Knife Center Seattle, Washington
2
Cats Eye Nebula

• The Cats Eye Nebula produces energy that
  is part of the Electromagnetic spectrum
• Located 3,000 light years away from our
  Milky Way Galaxy
• First planetary nebula to be discovered by
  the Hubble telescope
• Nebula are dying stars
• Chemical elements in the nebula emit light
  at very specific wavelength
• - Hydrogen Atoms Red
• - Oxygen Atoms Blue
• - Nitrogen Ions Green

3
Our Solar System

• The solar system was made from recycled
  elements originating from a dying star
  (Planetary Nebula)
• In terms of mass
• - 70 Hydrogen
• - 28 Helium
• - 1 Oxygen
• - 1 All Remaining Elements

4
C.H.O.N.
Carbon, Hydrogen, Oxygen and Nitrogen are so
common in clouds of gas and dust in space they
are simply referred to by the acronym C.H.O.N.
5
Body Mass
Water Weight - 65 H20 Dry Weight - 50
Carbon - 25 Oxygen - 10 Nitrogen - 15
All other elements combined We are made
from the 4 most reactive elements in the Universe
6
Radiation Therapy Machines
Radiation Therapy Machines produce energy from
the Electromagnetic Spectrum - Linear
Accelerator - CyberKnife - Gamma Knife
7
The Electromagnetic Spectrum

• It is the name given to the group of
  radiation types
• All radiation is a form of energy
• Energy in this example increases from left
  to right
• Energy is defined as ionizing or
  non-ionizing if it is large enough to remove
  electrons from their atoms.

8
DNA (DeoxyriboNucleic Acid)

• The effect of radiation on cancer cells is
  due to ionization or damage caused by the
  breakage of chemical bonds in the DNA molecule
• DNA damage prevents the cells from
  replicating
• As long as cancer cells cannot reproduce,
  they cannot grow in size or metastasize

9
Radiation Therapy Planning Session
The goal of radiation therapy is to injure more
cancer cells than normal cellsTo achieve this,
a treatment planning session or simulation is
undertaken prior to actual treatment. Many
variables need to be considered including -
Treatment Type - Field Size - Number of
Treatment Beams - Beam Direction - Beam
Modifiers (Blocks, Wedges, Tissue Compensators)
- Computerized Dosimetery Plan - Patient
Immobilization Device
10
Side Effects
The effects of radiation maybe temporary (because
the cell is able to repair it) or permanent (by
injuring the repair mechanism) and become
apparent anywhere from days to weeks to months to
years after exposure. Radiation injury is a
function of radiation type, dose, fraction size,
volume of tissue irradiated and area of the body
exposed
11
In 1992, the American College of Surgery reported
that only 10-40 of eligible candidates for
conservative surgery followed by radiation
therapy received it
12
Breast Conservation Therapy Treatment Objectives

• Acceptable cosmesis
• Local control of disease
• Minimal treatment complications

13
Rational for the Addition of Breast Irradiation
to Breast Conserving Surgery
Six randomized trials have shown breast
irradiation increases local control in all
subsets of patients with invasive ductal
carcinoma compared to surgery alone
14
External Beam Radiotherapy Treatment Option
Linear Accelerator
External Beam Treatment Plan
15
External Beam Radiotherapy Treatment Course

• 6 and ½ weeks, daily treatments, Monday through
  Friday
• 4500-5000 cGy to whole Breast followed by a
  10002100 cGy boost to the lumpectomy site
  bringing the entire dose to the surgical bed
  to between 6000 and 6600 cGy

16
Whole Breast Radiation Side Effects

• Acute Side Effects
• Fatigue
• Skin changes

• Chronic Side Effects
• Pneumonitis
• Lymphedema
• Rib Fracture
• Secondary Malignancy
• Skin Changes
• Pericarditis

17
Normal Tissue Tolerance To Therapeutic Radiation
Dose expected to give a 5 risk of injury at 5
years
18
Advantages of Partial Breast Irradiation Over
Whole Breast Treatment

• Decrease time and inconvenience
• Decrease acute and chronic toxicity
• Improved radiation therapy underutilization

19
Rational for Partial Breast Irradiation

• Studies which support the ability to achieve
  local
• control with partial breast irradiation include
• Mastectomy studies
• Margin assessment data
• Regional failure studies
• Partial breast irradiation clinical data

20
Eligibility Criteria for Partial Breast
Irradiation

• Infiltrating Ductal or Lobular Carcinoma pure
  DCIS
• Tumors ? 3.0 cm
• Age ? 45
• Negative margins ( ? 2.0mm)
• 0-3 Positive Node(s)

21
Techniques for Partial Breast Irradiation

• Intraoperative Radiotherapy
• 3-D Conformal External Beam Radiotherapy
• Multicatheter Brachytherapy
• Balloon Catheter Brachytherapy

22
Multi-Catheter Brachytherapy

• Method
• Local Anesthesia
• Placement during or after lumpectomy
• Treatment
• Outpatient
• High Dose Rate remote afterloader
• 3400 cGy /10 fractions given twice a day for 5
  days
• Catheter removed on 10th fraction in department

23
Multi-Catheter Brachytherapy
Treatment
Post-removal
54 month F/U
24
Balloon Catheter Brachytherapy Advantages Over
Other Types of PBI Techniques

• Short MD learning curve
• Improved target volume coverage
• Better patient tolerance
• Few complications

25
Complications of Partial BreastIrradiation
Techniques

• Pneumonitis
• Lymphedema
• Rib fracture
• Secondary Malignancy
• Skin Changes
• Pericarditis
• These complications are the same as those seen
  with whole breast irradiation. However, their
  incidence is less because the volume of tissue
  being irradiated is less.

26
Inserted obturator to prevent bending or coiling
of the catheter shaft
Radiation source port pathway
Multilumen, silicone catheter
Variable 4 to 5 cm balloon
Needleless injection site
Learn More Atwww.DoctorVermeulen.com
27
MammoSite Procedure
Un-inflated MammoSite is advanced into the
cavity through the Trocar path
Lumpectomy cavity is created
Trocar used to create pathway to cavity
The 192Ir source is advanced into the MammoSite
and radiation therapy is delivered per the
treatment plan
Design allows the 192Ir Source to be centrally
positioned within the applicator
MammoSite is inflated with saline/contrast to
position the tissue to receive radiation therapy
28
CT Image of Balloon Catheter
3-Dimensional rendering of applicator surface
29
MammoSite Cosmetic Evaluation
Post 30 days
Post 5 months
Pre-surgery
At 3 months, the MammoSite RTS provided good to
excellent cosmeticresults for more than 90 of
patients.
30
What Can Be Done to Minimize Normal Tissue Damage
from the Ionizing Effect of Breast Irradiation?

• Stop smoking
• Treat all other unrelated disease conditions
  aggressively such as, diabetes and infections
• Get adequate rest and exercise
• Lymphedema management therapy
• Eat right/see a dietician
• See a Naturopath
• - Vitamins (anti-oxidants), minerals
• Reduce stress
• - Bio-feedback therapy, psychotherapy, support
  groups
• - Seek Spiritual comfort
• Non-traditional western medicine approach to
  health
• - Yoga, meditation
• Hyperbaric oxygen therapy?

31
Conclusion
We are on the continued quest of study to harness
the benefits of energy produced by the
Electromagnetic Spectrum