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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
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• The Cat’s 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
Cat’s Eye Nebula
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• 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
Our Solar System
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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.
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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
Body Mass
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Radiation Therapy Machines produce energy from the Electromagnetic Spectrum
- Linear Accelerator
- CyberKnife
- Gamma Knife
Radiation Therapy Machines
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• 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.
The Electromagnetic Spectrum
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• 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
DNA (DeoxyriboNucleic Acid)
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The goal of radiation therapy is to injure more cancer cells than normal cells
To 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
Radiation Therapy Planning Session
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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
Side Effects
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In 1992, the American College of Surgery reported that only 10-40% of eligible
candidates for conservative surgery followed by radiation therapy received it
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Breast Conservation Therapy Treatment Objectives
• Acceptable cosmesis• Local control of disease• Minimal treatment complications
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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
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External Beam Radiotherapy Treatment Option
Linear Accelerator External Beam Treatment Plan
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• 6 and ½ weeks, daily treatments, Monday through Friday
• 4500-5000 cGy to whole Breast followed by a 1000–2100 cGy boost to the lumpectomy site bringing the entire dose to the surgical bed to between 6000 and 6600 cGy
External Beam Radiotherapy Treatment Course
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Whole Breast Radiation Side Effects
Acute Side Effects
• Fatigue• Skin changes
Chronic Side Effects
• Pneumonitis• Lymphedema• Rib Fracture• Secondary Malignancy• Skin Changes• Pericarditis
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Necrosis, Fracture6,000 (N/A)Bone
Chronic Dermatitis5,500 (N/A)Skin
Atrophy, Sclerosis5,000 (Whole Node)
Lymphatics
Pericarditis4,500 (80%)Heart
Pneumonitis2,000 (25%)
Lung
Side EffectcGy (Volume)Organ
Normal Tissue Tolerance To Therapeutic Radiation
Dose expected to give a 5% risk of injury at 5 years
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Advantages of Partial Breast Irradiation Over Whole Breast Treatment
• Decrease time and inconvenience
• Decrease acute and chronic toxicity• Improved radiation therapy underutilization
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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
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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)
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Techniques for Partial Breast Irradiation
• Intraoperative Radiotherapy• 3-D Conformal External Beam Radiotherapy• Multicatheter Brachytherapy• Balloon Catheter Brachytherapy
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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
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Treatment Post-removal 54 month F/U
Multi-Catheter Brachytherapy
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Balloon Catheter Brachytherapy Advantages Over Other Types of PBI Techniques
• Short MD learning curve• Improved target volume
coverage• Better patient tolerance• Few complications
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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.
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Variable 4 to 5 cm balloon
Multilumen, silicone catheter
Radiation source port pathway
Inserted obturator toprevent bending orcoiling of the catheter shaft
Needleless injection site
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MammoSite Procedure
Lumpectomy cavity is created
Trocar used to createpathway to cavity
Un-inflated MammoSite is advanced into the cavitythrough the Trocar path
MammoSite is inflated with
saline/contrast to position the tissue to
receive radiation therapy
Design allows the 192IrSource to be centrally positioned within the
applicator
The 192Ir source is advanced into the MammoSite and
radiation therapy is delivered per the treatment plan
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3-Dimensional rendering of applicator surface
CT Image of Balloon Catheter
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MammoSite Cosmetic Evaluation
At 3+ months, the MammoSite RTS provided good to excellent cosmetic
results for more than 90% of patients.
Pre-surgery Post 30 days Post 5 months
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• 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?
What Can Be Done to Minimize Normal Tissue Damage from the Ionizing Effect of Breast Irradiation?
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We are on the continued quest of study to harness
the benefits of energy produced by the Electromagnetic
Spectrum
Conclusion