4.6 Schleicher, GammaMed and MammoSite - Varian

Gammamed
and MammoSite
for breast IORT
Breast Cancer Center Düren
U M Schleicher, E M Bosch, W Hürter
Radiotherapy
L Paas, M Türker
Gynaecology

Methods of partial breast irradiation
Percutaneous
– conformal 3D planned
Interstitial
– Iridium wires
– Balloon catheter
Intraoperative
– Electrons
– X-rays

ASTRO criteria for APBI as sole
Suitable
IJROPB 2009
74:987-1001
treatment

ASTRO criteria for APBI as sole
cautionary:
IJROPB 2009
74:987-1001
treatment

ASTRO criteria for APBI as sole
Unsuitable:
IJROPB 2009
74:987-1001
treatment

PBI- the German situation
S3 Guidelines for breast cancer treatment
– partial breast irradiation as a tumor bed boost before
or after whole breast irradiation
– may be performed with
Electrons
Interstitial: multicathter- or balloncatheter techniques
3D-conformal percutaneous
Protons only experimental
Intraoperativ
– Electrons or X-rays
– technique does not influence results of therapy

PBI- the German situation
Federal Ministry for Nuclear Safety on breast
IORT with X-ray (June 2011):
– only as boost with obligatory percutaneous WBI
– Physician and Physicist must have the
qualification in radiation protection for
radiotherapy
– Individual treatment plan obligatory

TARGIT Results:
Non-inferiority to WBI
Vaidya et al.: www.thelancet.com Published online June 5, 2010
DOI:10.1016/S0140-6736(10)60837-9

Vaidya et al.: Lancet 2010
TARGIT: Method
•50 kV-X-ray, different applicator sizes
•20 Gy on applicator surface = 5-7 Gy in 1 cm depth
© Zeiss

Dose distributions
Recommended for 3Dconformal PBI
•CTV =lumpectomy cavity +1.5 cm
5 mm from the skin surface
5 mm from the lung–chest wall interface
• PTV = CTV
+0.5 cm for breathing motion
+0.5 cm for expected variation in patient setup
Offersen, Overgaard, Kromann, Overgaard,
RadiotherOncol 2009; 90:1-13
© ESO

Treatment Modality for IORT
spherical isodose
Sufficient dose
distribution
Easy to perform
No time-consuming
planning possible
(anaesthesia!)
Obeyence of legal
restrictions

Material
© Varian Medical Systems
© Medicor

Dose distribution
Dose
(Gy)
12
10
8
6
4
2
0
4
Dose in 1cm depth
4,5
5
5,5
balloon diameter (cm)

NSBAP B-39 RTOG 04-13
Placement into closed cavity (post surgery)
3D treatment planning
PTV = breast tissue 1cm around balloon
3,4 Gy bid for 5 treatment days
6 h interval
34 Gy total dose
Deflation of balloon and removal (-> seroma
in cavity?)

Treatment Modality for IORT
spherical isodose
Sufficient dose
distribution
Easy to perform
No time-consuming
planning possible
(anaesthesia!)
Obeyence of legal
restrictions
one stop point
Gamma Energy :
– γ 316 keV (86%)
Single catheter
Standard plans for
different volumes
Informed consent
(IORT and EBRT)
Brachytherapy qualification of
doc and physicist

Informed Consent
for percutaneous and IORT

Patient Check-List
Radiotherapy parts:
filled in by
radiotherapist
Senology parts:
filled in by
gynaegologist

Performance
Indication für BCS and boost RT
Tumor > 1.5 cm from skin and chest wall
Informed consent of patient
Tumor excision, ballon placement
Transport to brachytherapy unit
IORT (20 Gy surface = 8.8-10 Gy in 1 cm)
Transport to operation theatre
Finishing of oncoplastic surgery

Dose measurement
5-fold semiconductor probe
Dose limit: 8 Gy

100
80
60
40
20
0
10
8
6
4
2
0
Patients
aged 36-82 ys., 16 G2 + 4 G3
Tumor stage: all patients=220/128)
BZ DN KH DN
Tis T1 T2 T3 T4
ASTRO criteria for PBI only
suitable cautionary unsuitable
14
12
10
8
7
6
5
4
3
2
1
0
8
6
4
2
0
Tumor Stage IORT
T1a T1b T1c T2
Mammosite volume
35 ml 40 ml 50 ml

Side effects
After 5 days After 6 weeks
Erythema 3/20 3/20
Epitheliolysis none none
Pigmentation none 1/20
Edema 4/20 1/20
Seroma 3/20 1/20
Induration 5/20 8/20
No toxicity grade 3

Cosmetic results: patients‘ view
patients
18
16
14
12
10
8
6
4
2
0
grade 0 grade 1 grade 2 grade 3
5 days 6 weeks 3 months

Advantages and Disadvantages of
mammosite vs. intrabeam
dose distribution
– 8.8 to 10 Gy vs. 5-7 Gy in 1 cm
– applicator-skin distance 1.5 vs. 1 cm
online dose measurement
equal time for treatment
– including transport to brachytherapy unit
brachytherapy unit existing -> no investment in
machines, payment for catheters per patient
treated -> IORT possible in smaller breast units