Congreso Portugués de Oncología Radioterápica

Porto, 27 al 29 de Enero 2011

APBI future: My point of view.

Dr. F. Guedea – 28 de enero 2011

Institut Català d’Oncologia

1. The future for RT in Breast cancer
cancer::
1.1 Hypofractionation in Breast Cancer
1.2 IMRT in Breast Cancer
1.3 APBI
2. Rationale for APBI
APBI::
3. Modalities of APBI
APBI::
4. Literature review for APBI
APBI::
5. Catalan Institute of Oncology experience
experience..
6. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 Phase III trials for
hypofractionation in Breast cancer

1.RMH/GOC Phase III Trial (UK): 1986-

1986-1998
2.Ontario Phase III Trial (Canada): 1993-
1993-1996
3.START A Phase III Trial (UK): A 1999-
1999-2002
4.START B Phase III Trial (UK): 1999-
1999-2001

J. Yarnold, S. Bentzen et al.

Hypofractionated whole-breast RT for women with early breast cancer:
Myths and realities.
IJROBP in press. Accepted august 2010.

Institut Català d’Oncologia

 Phase III trials for
hypofractionation in Breast cancer

2.Ontario Phase III (Canada, Whelan et al.)1993-

al.)1993-1996
50.0/25/5.0 (2.0) LR: 3.2% Good Cosmesis: 79.2%
42.5/16/3.2 (2.66) LR: 2.8% Good Cosmesis: 77.9%
with median FU > 132 months
1234 patients

Whelan T., et al..

Long-term results of Hypofractionated RT for breast cancer:
NEJM 362: 513-520. 2010

Institut Català d’Oncologia

1. The future for RT in Breast cancer
cancer::
1.1 Hypofractionation in Breast Cancer
1.2 IMRT in Breast Cancer
1.3 ABPI
2. Rationale for APBI
APBI::
3. Modalities of APBI
APBI::
4. Literature review for APBI
APBI::
5. Catalan Institute of Oncology experience
experience..
6. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 Three phase III study published for Breast
tumors (Comparing IMRT vs Standard RT)

Donovan E., Yarnold J., et al.

Rad. & Oncol. 82, 254-
254-264. 2007.
Randomised trial of standard 2D RT vs IMRT in 306 patients.
Incidence of change in breast appearance was higher with standard RT
compared to IMRT (P=0.008).

Pignol JP., Olivotto I., et al.

JCO. 15, 2488-
2488-2493. 2007.
Randomised trial of 3D RT vs IMRT in 358 patients
IMRT compared to conventional RT (P=0.002) significantly reduces the
development of severe moist descamation (31.2 vs 47.8%).

Institut Català d’Oncologia

 Breast IMRT Phase III trial

Barnett G., et al.

Radio. & Oncol
Oncol.. 92, 34
34--41. 2009.
A randomised controlled trial of forward
forward--planned RT (IMRT) for 1145 patients
with early breast cancer
cancer:: baseline characteristics and dosimetry results
results..

 Conclusion: This trial confirmed that dosimetry can be significantly

Conclusion:
improved with a simple method of forward-
forward-planned dosimetry
dosimetry.. It is shown
that patients with larger breasts are more likely with dose inhomogeneities
and breast separation gives some indications of this likelihood likelihood..
Photographs assessment of patients at 2 years after RT, as the next part of
this randomised controlled trial, will show whether these results for IMRT
translate into improved cosmetic outcome
outcome..

Institut Català d’Oncologia

1. The future for RT in Breast cancer
cancer::
2. Rationale for APBI
APBI::
3. Modalities of APBI
APBI::
4. Literature review for APBI
APBI::
5. Catalan Institute of Oncology experience
experience::
6. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 Rationale for APBI

Location of local recurrence in the breast after tumorectomy

Authors Nº cases Nº recurrences Nº recurrences in
the same quadrant

Clark 1982 680 87 84 ( 96 % )

Schnitt 154 12 10 ( 83 %)
Clarke 1985 436 15 9 ( 60 % )
Leung 1986 493 48 36 ( 75 % )
Limbergen 1987 238 22 19 ( 86 % )
TOTAL 1991 184 158 ( 86 % )

Veronesi,, Milan,
Veronesi Milan, 12 year follow
follow--up. 86% local relapses in the same quadrant
quadrant..

Institut Català d’Oncologia

 Rationale for APBI

Vrieling C., Bartelink H, et al. En nombre

del EORTC Radiotherapy Breast Cancer Group
Eur. J. of Cancer (Ed. Española) 3, 378-390. 2003.
Las características relacionadas con el paciente, el tratamiento y la patología
¿Pueden explicar el alto porcentage de recidiva?

• Porcentage de control local a los 5 años:

os: 82%
82% en pacientes de
menos de 35 años.os.
• Porcentage de control local a los 5 años:
os: 85%
85% en pacientes de
36--40 años
entre 36 os..
• Porcentage de control local a los 5 años:
os: 92%
92% en pacientes de
41--50 años
entre 41 os.. P<0,001
• Porcentage de control local a los 5 años:
os: 96%
96% en pacientes de
51--60 años.
entre 51 os.
• Porcentage de control local a los 5 años:
os: 97%
97% en pacientes de
más de 60 años

Institut Català d’Oncologia

Selected patients
patients::
• elderly patients (Sup to 55
55--60 years
years))
• T1 tumors
• Estrogen receptors positive
• Without EIC
• Without lymphovascular invasion APBI
• Negative axillary nodes
• Margins free

Fowble B, Radiother Oncol 55, 26, 2000

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
2.1 Multicatheters Technique.
2.2 Baloon Technique (Mamosite).
2.3 IORT with electrons.
2.4 IORT with Intrabeam.
2.5 Electronic Brachytherapy (Xoft).
2.6 EBRT with 3-3-D or IMRT.
2.7 Seeds.
2.8 Non invasive Brachytherapy (Accuboost)
3. Literature review for APBI:
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 2.1 Multicatheters technique: advantages
• Tumor parameters are exactly know at the time of implant (If the
implant is done postoperative).
postoperative).
• Target volume coverage is not limited in form and volume.
volume.
• Very good reproducibility
reproducibility..
• Treatment planning simple and reliable.
reliable.

Institut Català d’Oncologia

2.1 Multicatheters technique: disadvantages

• Individually long learning curve.

• Some puncture sites

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
2.1 Multicatheters Technique.
2.2 Baloon Technique (Mamosite).
2.3 IORT with electrons.
2.4 IORT with Intrabeam.
2.5 Electronic Brachytherapy (Xoft).
2.6 EBRT with 3-3-D or IMRT.
2.7 Seeds.
2.8 Non invasive Brachytherapy (Accuboost)
3. Literature review for APBI:
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

2.2 Balloon technique: advantages

• Short learning curve.

• Good reproducibility.
• One puncture site.

Institut Català d’Oncologia

 2.2 Balloon technique: disadvantages
• Volume coverage is very limited in form and volume.
• Tumor parameters are not exactly know at the time of implant
• Dose to the skin.

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
2.1 Multicatheters Technique.
2.2 Baloon Technique (Mamosite).
2.3 IORT with electrons.
2.4 IORT with Intrabeam.
2.5 Electronic Brachytherapy (Xoft).
2.6 EBRT with 3-3-D or IMRT.
2.7 Seeds.
2.8 Non invasive Brachytherapy (Accuboost)
3. Literature review for APBI:
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 2.3 Single fraction 21 Gy with an IORT
dedicated accelerator : advantages
• Good target volume coverage with sufficient dose.

Institut Català d’Oncologia

2.3 Single fraction 21 Gy with an IORT
dedicated accelerator : disadvantages

• Tumor parameters are not exactly known at the

time of irradiation.
• Availability of this expensive system is limited.

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
2.1 Multicatheters Technique.
2.2 Baloon Technique (Mamosite).
2.3 IORT with electrons.
2.4 IORT with Intrabeam.
2.5 Electronic Brachytherapy (Xoft).
2.6 EBRT with 3-3-D or IMRT.
2.7 Seeds.
2.8 Non invasive Brachytherapy (Accuboost)
3. Literature review for APBI:
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 2.4 Single fraction with 50 kV x-ray
machine: advantages

• More flexibility
compared with single
fraction from a Linac.
• Less expensive system
compared to dedicated
IORT Linac.

Institut Català d’Oncologia

 2.4 Single fraction with 50 kV x-ray
machine: disadvantages

• Tumor parameters are not exactly known at the

time of irradiation.
• Dose distribution is limited in form and volume.
• Insuficient 20 Gy surface and 5-6 Gy single
fraction in 1 cm tissue depth?

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
2.1 Multicatheters Technique.
2.2 Baloon Technique (Mamosite).
2.3 IORT with electrons.
2.4 IORT with Intrabeam.
2.5 Electronic Brachytherapy (Xoft).
2.6 EBRT with 3-3-D or IMRT.
2.7 Seeds.
2.8 Non invasive Brachytherapy (Accuboost)
3. Literature review for APBI:
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

2.5 Electronic Brachytherapy with an
HDR X-Ray source: advantages

• No radioactive isotopes
• Minimal room shielding requirements.

Institut Català d’Oncologia

 2.5 Electronic brachytherapy with an
HDR X-Ray source: disadvantages

• Minimal clinical references and information

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
2.1 Multicatheters Technique.
2.2 Baloon Technique (Mamosite).
2.3 IORT with electrons.
2.4 IORT with Intrabeam.
2.5 Electronic Brachytherapy (Xoft).
2.6 EBRT with 3-3-D or IMRT.
2.7 Seeds.
2.8 Non invasive Brachytherapy (Accuboost)
3. Literature review for APBI:
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

2.6. External radiation therapy with 3-D or
IMRT: advantages
• Tumor parameters are exactly know at the time of external beam.
• Target volume coverage is not limited in form and volume.

Institut Català d’Oncologia

2.6 External radiation therapy with 3-D or
IMRT: disadvantages

• Daily breast fixation and reproducibility.

• High integral dose.

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
2.1 Multicatheters Technique.
2.2 Baloon Technique (Mamosite).
2.3 IORT with electrons.
2.4 IORT with Intrabeam.
2.5 Electronic Brachytherapy (Xoft).
2.6 EBRT with 3-3-D or IMRT.
2.7 Seeds.
2.8 Non invasive Brachytherapy (Accuboost)
3. Literature review for APBI:
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 2.7 Brachytherapy with seeds:
Advantages.
• Invasive treatment with a technique very usefull in other
locations.

Institut Català d’Oncologia

 2.7 Brachytherapy with seeds:
disadvantages

• Minimal clinical references and information.

• Mammography FU with seeds?

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
2.1 Multicatheters Technique.
2.2 Baloon Technique (Mamosite).
2.3 IORT with electrons.
2.4 IORT with Intrabeam.
2.5 Electronic Brachytherapy (Xoft).
2.6 EBRT with 3-3-D or IMRT.
2.7 Seeds.
2.8 Non invasive Brachytherapy (Accuboost)
3. Literature review for APBI:
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 2.8 Non-Invasive HDR Brachytherapy
with AccuBoost: Advantages.
• Non invasive treatment
• HDR
• Mammography based IGRT
with CR System for digital
Image.
• Different apllicators.
• Minimal exposure to heart
and lungs.

Institut Català d’Oncologia

 2.8 Non-Invasive HDR brachytherapy
with AccuBoost: disadvantages

• Minimal clinical references and information.

• Daily Mammography.
• Dose to the skin.
• Necesity of a Mammography Unit for the
treatment.

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
3. Literature review for APBI
APBI::
– Phase I-II trials
– Phase III trials
– Ongoing Phase III trials
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 Vicini F., Martinez A., et al.
Int. J. Radiat. Oncol. Biol. Phys. 69, 1124-1130. 2007.
Interim cosmetic results and toxicity using 3D CRT to
deliver APBI ( 34-38.5 Gy in 10 fractions over 5 consecutive
days) in 91 pts with early breast cancer

• Conclusion:
Conclusion: Delivery of APBI with 3D-CRT
resulted in minimal chronic (> (>66 months)
toxicity to date with good/excellent cosmetic
results.. Additional FU is needed to assess
results
the long term efficacy of this form of APBI
APBI..

Institut Català d’Oncologia

 3-DCRT APBI: Summary

T size Local
Pt. Median F/U (cm) N+ ER + relapse
Institution No. age mo. median % % %

Beaumont 92 62 23 - 2 - 0

NYU 78 67.5 28 0.9 0 100 0

12
MGH 61 62
(min)
0.9 0 - 0

RTOG 42 61 - 0.85 - - -
0319

Institut Català d’Oncologia

 Ott O., Pötter R., Strnad V., et al.
Radiat. & Oncol. 82, 281-286. 2007.
Accelerated Partial Breast Irradiation (APBI) with multi-
catheter brachytherapy: local control (LC), side effects and
cosmetic outcome for 274 patients. Results of the German-
Austrian multi-centre trial.

• Conclusion:
Conclusion: LC was 99 99,,3%, and 3y local
recurrence Free Survival was 99 99,,6%. Late
effects≥ Grade 3 occurred in 1.8%. This
analysis underlined the safety and effectiveness
of APBI
APBI..
Institut Català d’Oncologia
 MultiCatheter APBI: HDR/ LDR Summary

Exc/
Exc/
T size good
Pt. Median F/U N+ ER + Tam LR
(cm) Cosmesis
No. age mo. % % % %
Institution median %

Oschner 51 63 75 1.4 18 - - 2 -

Beaumont 199 65 65 1.1 12 - 57 1.2 99

Tufts-NEMC 32 63 33 1.3 9 79 61 3 88

VCU 44 62 42 1.2 18 - 66 0 80
Nat. Inst.
Onc. 45 56 81 1.2 2 82 16 6.7 97
Budapest
Guys Cs 137 49 58 75 2.5 46 - - 18 81
Institut Català d’Oncologia
 APBI with Mammosite
MF. Clemente, J. Garcia, MT. Murillo, et al.
Rev. Fis. Med. 10, 133-
133-137. 2009.
Irradiación parcial de la mama con el palicador Mammosite:
Primera experiencia en España.

Vicini F., et al.

Cancer 15, 112, 758-
758-766. 2008.
3-year analysis of treatment efficacy, cosmesis, and toxicity in pactients treated
with APBI using MammoSite

Benitez P., Keisch M., Vicini F., et al.

The American Journal of Surgery 194, 456- 456-462, 2007.
5-year results: the initial clinical trial of Mammosite balloon brachytherapy
for APBI in early-
early-stage breast cancer
Excellent cosmetic results in 83.3% and 5y local recurrence similar to BCT
with a median FU of 5.5 y.

Institut Català d’Oncologia

 MammoSite PBI: summary

Exc/
T size Local good
Pt. Median F/U N+ ER +
Institution (cm) relapse
No. age mo. % % Cosmesis
median %
%

Initial Multi-
Multi-
43 69 48 1.0 0 - 0 80
Institutional

88%
Rush Univ. 112 64 - 7 - 0 80
Tis--T1
Tis

Tufts-NEMC/
Tufts-
28 62 19 1.1 0 100 0 86
VCU

St. Vincent
32 62 11 97% T1 9 94 - 86
Hospital

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
3. Literature review for APBI
APBI::
– Phase I-II trials
– Phase III trials
– Ongoing Phase III trials
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 Polgar C., et al.
Int. J. Radiat. Oncol. Biol. Phys. 69, 694-702. 2007.
Breast conserving treatment with Partial breast irradiation with
HDR multicathethers (PBI, 128 pts, 7 x 5.2 Gy) or whole breast
irradiation (WBI, 130 pts, 50 Gy) for low-risk breast cancer
patients: 5-y results of a randomized trial phase III of 258 pts

• Conclusion:
Conclusion: At a median FU of 66 months, the
results are similar
similar:: OS (94.
94.6% vs 91.
91.8%), DFS
(88
88..3% vs 90.
90.3%), LR (4.7% vs 3.4%). For
cosmetic results
results:: 81.
81.2% in APBI vs 7070%
% in
WBI (p=
(p=0
0.009
009)).
Institut Català d’Oncologia
 1119 WBRT
with a dose of 45-
45-56 Gy
with or without a boost of 10-
10-16 Gy

2232 patients randomised to: vs

1113 with IntraopRT

with a dose of 20 Gy surface and 55--7 Gy at
1 cm (856 Targit only and 142 Targit and
EBRT)

Vaidya J., Saunders M., et al. (28 centres in 9 countries)

Targeted intraoperative RT vs WBRT for breast cancer (TARGIT-A Trial):
an international, prospective, randomised, non inferiorty Phase III Trial.
Lancet 376, 91-102. 2010.

Institut Català d’Oncologia

Local recurrence at 4y.: 1,2% in Targit and 0.95% in WBRT
Major Toxicity = in both groups (p=0.44)
RT Toxicity Grade III was lower in Targit Group (0.5%)
compared with the WBRT group (2.1%) (p=0.002)

Vaidya J., Saunders M., et al. (28 centres in 9 countries)

Targeted intraoperative RT vs WBRT for breast cancer
(TARGIT-A Trial):
an international, prospective, randomised, non inferiorty Phase III Trial.
Lancet 376, 91-102. 2010.

Institut Català d’Oncologia

 … In a series of 2232 patients, (1119 with WBRT and 1113
with Intraoperative RT -856 Targit only and 142 Targit
and EBRT-
EBRT- with a dose of 20 Gy surface and 5- 5-7 Gy at 1 cm),
a single dose of RT delivered at the time o surgery by use
of targeted intraoperative RT should be considered as an
alternative to EBRT delivered over several weeks….

Vaidya J., Saunders M., et al. (28 centres in 9 countries)

Targeted intraoperative RT vs WBRT for breast cancer

(TARGIT-A Trial): an international, prospective, randomised,
non inferiorty Phase III Trial.

Lancet 376, 91-102. 2010.

Institut Català d’Oncologia

1. Rationale for APBI
APBI::
2. Modalities of APBI
APBI::
3. Literature review for APBI
APBI::
– Phase I-II trials
– Phase III trials
– Ongoing Phase III trials
4. Catalan Institute of Oncology experience
experience..
5. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 Ongoing Phase III trials for
APBI in Breast cancer

1. GEC
GEC--ESTRO Phase III trial (Europe)
2. NSABP BB--39 / RTOG0413 Phase III Trial (USA)
3. ELIOT Phase III Trial (Milan, Italy)
4. Rapid Phase III Trial (Canada)
5. Irma Phase III Trial (Italy)

J. Yarnold, and J. Haviland.

Pushing the limits of hypofractionation of adjuvant WBRT.
The Breast 19. 176-179. 2010.

Institut Català d’Oncologia

 Polgar C., Van Limbergen, Polo A., Guedea F., et al.
Radiotherapy and Oncology 94, 264-273. 2010.
Patient selection for APBI after breast-conserving surgery:
recommendations of the GEC-ESTRO breast cancer working
group based on clinical evidence.

• Conclusion:
Conclusion: These recommendations will provide a clinical
guidance regarding the use of APBI outside the context of a
clinical trial before large-
large-scale randomized trial outcome data
become available
available.. Furthermore they should promote further
clinical research focusing on controversila issues in the
treatment of early
early--stage breast carcinoma
carcinoma..

Institut Català d’Oncologia

 Polgar C., Van Limbergen, Polo A., Guedea F., et al.
Radiotherapy and Oncology 94, 264-273. 2010.
Patient selection for APBI after breast-conserving surgery: recommendations of the
GEC-ESTRO breast cancer working group based on clinical evidence.

Institut Català d’Oncologia

 Smith B., Arthur D., Buchholz T., Vicini F.,
Whelan T., Harris J., et al.
Int. J. Radiat. Oncol. Biol. Phys. 74, 987-1001. 2009.
APBI consensus statement from the ASTRO.

• Conclusion:
Conclusion: The Task force proposed 3 patients groups groups::1) A “suitable
suitable””
acceptable,, 2) A “cautionary
group,, fo whom APBI ouside a clinical trial is acceptable
group
group”
group ”, from whom caution and concern should be applied when
considering APBI outside of a clinical trial and 3) An “unsuitable
unsuitable”” group
group,,
for whom APBI outside a clinical trial is not generally considered
warranted.. Patients who choose treatment with APBI should be informed
warranted
that whole
whole--breast irradiation is an establised treatment with a much longer
track record that has documented long
long--term effectiveness and safety
safety..

Institut Català d’Oncologia

 Smith B., Arthur D., Buchholz T., Vicini F.,
Whelan T., Harris J., et al.
Int. J. Radiat. Oncol. Biol. Phys. 74, 987-1001. 2009.
APBI consensus statement from the ASTRO.

Institut Català d’Oncologia

 Smith B., Arthur D., Buchholz T., Vicini F.,
Whelan T., Harris J., et al.
Int. J. Radiat. Oncol. Biol. Phys. 74, 987-1001. 2009.
APBI consensus statement from the ASTRO.

Institut Català d’Oncologia

 Smith B., Arthur D., Buchholz T., Vicini F.,
Whelan T., Harris J., et al.
Int. J. Radiat. Oncol. Biol. Phys. 74, 987-1001. 2009.
APBI consensus statement from the ASTRO.

Institut Català d’Oncologia

1. The future for RT in Breast cancer
cancer::
2. Rationale for APBI
APBI::
3. Modalities of APBI
APBI::
4. Literature review for APBI
APBI::
5. Catalan Institute of Oncology experience
experience::
6. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

 Our team has selected the
multicatheters technique at ICO

1. Tumor parameters are exactly know at the time of implant.

implant.
2. Target volume coverage is not limited in form and volume
volume..
3. Very good reproducibility
reproducibility..
4. Treatment planning simple and reliable.
reliable.
5. Our experience in multicatheters technique
technique..

Institut Català d’Oncologia

Step-by-Step multicatheters technique

Institut Català d’Oncologia

 Our team has selected the
Balloon technique at Dexeus
1. Short learning curve.
2. Good reproducibility.
3. One puncture site.
4. Excellent integration between surgeons and Radiation
Oncologists.

Institut Català d’Oncologia

 Purpose & Materials (APBI)

• To evaluate our experience with brachytherapy alone used as a partial

breast irradiation technique following conservative breast
surgery(lumpectomy).

• This was a phase II single-center trial of 42 patients between 66 to 89

years old with early breast cancer. High-dose rate brachytherapy (HDR-BT)
was applied through plastic catheters in all cases.

• Ultrasound localization was used to insert the catheters into the border area
of the surgical bed.

• Ten fractions of 3.4 Gy each were administred, b.i.d. (twice daily), at

intervals of at least 6 hours. After tube placement, a CT was performed to
evaluate dosimetry.

• The mean follow up was 4.5 years (1.4-5.3y)

RADIATION THERAPY DEPARTMENT Institut Català d’Oncologia

RADIATION THERAPY DEPARTMENT Institut Català d’Oncologia
RADIATION THERAPY DEPARTMENT Institut Català d’Oncologia
 Treatment outcome
Treatment and
outcome
cosmetic results (APBI)

• One patient (2,38%) had a local relapse requiring salvage mastectomy.

• A second patient (2,38%) developed multiple bone and lung metastases and
died in September 2009.

• A third patient (2,38%) was diagnosed with a primary lung

adenocarcinoma (treated with chemotherapy) and bone metastasis, wich
was treated with palliative radiotherapy.

• The remaining 39 (92,86%) patients are alive free of disease.

• Cosmetic results are excellent in 24 patients (57,14%), good in 3 patients

(7,14%), bad in 6 patients (14,29%), the remaining 9 no cosmetic results
evaluated.

RADIATION THERAPY DEPARTMENT Institut Català d’Oncologia

1. The future for RT in Breast cancer
cancer::
2. Rationale for APBI
APBI::
3. Modalities of APBI
APBI::
4. Literature review for APBI
APBI::
5. Catalan Institute of Oncology experience
experience::
6. General Conclusions
Conclusions::

ICO+centre. Servei/Unitat Institut Català d’Oncologia

... Recent randomized trials justify the routine
use of modest hypofractionation with APBI
in women with early breast cancer ...
...

Modified from J. Yarnold, S. Bentzen et al.

Hypofractionated whole-breast RT for women with
early breast cancer: Myths and realities.
IJROBP in press. Accepted august 2010.

Institut Català d’Oncologia

 …WBI in a conventional course
remains the gold standard, and
patients should be so informed….

Prosnitz L., Horner J., and Wallner P.

Int. J. Rad. Oncol. Biol. Phys. 74, 981-984. 2009.

APBI: caution and concern form an ASTRO Task Force.

Institut Català d’Oncologia

… In elderly patients, we are already convinced
that APBI is the new standard
and intraoperative RT an excellent approach….

Azria D., and Bourgier C.

Partial Breast Irradiation: new standard for selected

patients.

Lancet 376, 71-72. 2010.

Institut Català d’Oncologia

 www.iconcologia.net
Institut Català d’Oncologia

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RADIATION THERAPY DEPARTMENT Institut Català d’Oncologia

RADIATION THERAPY DEPARTMENT Institut Català d’Oncologia
RADIATION THERAPY DEPARTMENT Institut Català d’Oncologia