CyberKnife Radiosurgery in the Treatment of Early and Advanced (Oligo-Metastases) Breast Cancer

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CyberKnife Radiosurgery in the Treatment of Early
and Advanced (Oligo-Metastases) Breast Cancer

• Sandra Vermeulen, MD
• Co- Director,
• Seattle CyberKnife Center
• Seattle, Wa

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Disclosures

• Accuray (vendor of Cyberknife)

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Breast Conservation Therapy Treatment Objectives

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

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In 2000 the National Cancer Data Base reported
that only 50 of eligible candidates received
conservative surgery followed by radiation therapy
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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

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External Beam Irradiation
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External Beam Coverage of the Breast and
Inclusion of Normal Tissues
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Advantages of Partial Breast Irradiation over
Whole Breast Treatment

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

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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
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Techniques for Partial Breast Irradiation

• 3-D conformal external beam radiotherapy
• Multi-catheter brachytherapy
• Balloon catheter brachytherapy
• Intra-operative Radiotherapy

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Multi-Catheter Brachytherapy
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Multi-Catheter Brachytherapy
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3-D Conformal Irradiation Technique
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Balloon Catheter Brachytherapy
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IORT

• Veronesi et al A preliminary report of IORT in
  limited stage breast cancers that are
  conservatively treated. Eur J Cancer. 2001
  Nov37(17)2178-83
• Mobile linear accelerator
• 3-9 Mev eb
• 10-21 Gy in 103 patient
• No complications

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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

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NSABP Dose Prescription

• 3D Conformal External Beam Radiotherapy
• 38.00 Gy total dose at 3.85 Gy per fraction
  delivered twice daily in 10 fractions over 5
  treatment days
• Multi-Catheter and Balloon catheter Brachytherapy
• 34 Gy total dose at 3.4 Gy per fraction delivered
  twice daily in 10 fractions over 5 treatment
  days

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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
  motion and variability of treatment set-up

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Novel Techniques for Partial Breast Irradiation

• CyberKnife

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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

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How is the technology different?

• Advanced interactive robotics
• Real-time imaging
• Dynamic automated motion tracking
• Flexible and accurate linac multiple-beam
  radiation delivery

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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, LEDs on the exterior of the patient
  are correlated with the movement of the
  target/tumor and fiducials

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Fiducial Tracking

• Gold seeds
• 5.0 mm x 0.9-1.2 mm

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Respiratory Tracking
SynchronyTM
Gating
Treatment Field
Over-treated healthy tissue
1.
2.
Beam Off
Beam On
3.
4.
Beam On
Beam Off
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
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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

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Cyberknife Demonstration
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Cyberknife Beam Profile
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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 gt 40

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A phase II Study of CyberKnife Radiosurgery
delivered to the Partial Breast for Women with
Stage 0, I, II Breast Cancer

• Seattle CyberKnife

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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

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Patient Eligibility

• Stage 0, I, II non-lobular breast cancer
• Cancer must be 3 cm
• Surgical treatment must be a lumpectomy
• Margins must be gt 2mm for both DCIS and invasive
  disease
• Negative sentinel Lymph node(s) or an axillary
  dissection
• Lumpectomy cavity must be clearly delineated

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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

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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

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Cyberknife PBI Treatment Volume
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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

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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

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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