Targit Surgical aspects in IORT - Dansk Brystkirurgisk...
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Transcript of Targit Surgical aspects in IORT - Dansk Brystkirurgisk...
Targit
Surgical aspects in IORT
Niels Bentzon
Dept. of Breast Surgery
Herlev-Gentofte Hospital
University of Copenhagen
DK-2730 Herlev
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
TARGIT protocols
• Targit A: ”IORT vs. EBRT”
• Targit B: ”Boost”
• Targit C: ”Baloon”
• Targit D: ”DCIS”
• Targit E: ”Elderly”
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
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
Tecnical problems
1. Intrabeam stops during treatment
2. Intrabeam delivered wrong dose: 7 pts. treated with a 20% overdose
radiation deeper into the tissue
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
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
Thank You
helmer@danskjävlar.dk
Herlev Hospital
Rigshospitalet