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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


• 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


• 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


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.


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


Radiation Therapy Machines produce energy from the Electromagnetic Spectrum

- Linear Accelerator

- CyberKnife

- Gamma Knife

Radiation Therapy Machines


• 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


• 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)


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


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


In 1992, the American College of Surgery reported that only 10-40% of eligible

candidates for conservative surgery followed by radiation therapy received it


Breast Conservation Therapy Treatment Objectives

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


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


External Beam Radiotherapy Treatment Option

Linear Accelerator External Beam Treatment Plan


• 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


Whole Breast Radiation Side Effects

Acute Side Effects

• Fatigue• Skin changes

Chronic Side Effects

• Pneumonitis• Lymphedema• Rib Fracture• Secondary Malignancy• Skin Changes• Pericarditis


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


Advantages of Partial Breast Irradiation Over Whole Breast Treatment

• Decrease time and inconvenience

• Decrease acute and chronic toxicity• Improved radiation therapy underutilization


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


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)


Techniques for Partial Breast Irradiation

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


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


Treatment Post-removal 54 month F/U

Multi-Catheter Brachytherapy


Balloon Catheter Brachytherapy Advantages Over Other Types of PBI Techniques

• Short MD learning curve• Improved target volume

coverage• Better patient tolerance• Few complications


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.


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



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


3-Dimensional rendering of applicator surface

CT Image of Balloon Catheter


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


• 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?


We are on the continued quest of study to harness

the benefits of energy produced by the Electromagnetic

Spectrum

Conclusion

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