Learn More At: CyberKnife Radiosurgery in the Treatment of Early and Advanced (Oligo-Metastases) Breast Cancer Sandra Vermeulen, MD Co- Director, Seattle CyberKnife Center Seattle, Wa

Learn More At: Disclosures Accuray (vendor of Cyberknife)

Learn More At: Breast Conservation Therapy Treatment Objectives Acceptable cosmesis Local control of disease Minimal treatment complications

Learn More At: In 2000 the National Cancer Data Base reported that only 50% of eligible candidates received conservative surgery followed by radiation therapy

Learn More At: Prospective Randomized Trials BCS + RT vs MRM Trial LR % Survival % F/U BCT vs MRM BCT vs MRM Years NSABP 14 v v Milan 9 v 2 59 v 59 20

Learn More At: External Beam Irradiation

Learn More At: External Beam Coverage of the Breast and Inclusion of Normal Tissues

Learn More At: Advantages of Partial Breast Irradiation over Whole Breast Treatment Decreased time and inconvenience Decreased acute and chronic toxicity Improved radiation therapy underutilization

Learn More At: Regional Failures within the Breast TrialCS AloneCS + RT NSABP2.7 17/ /629 Ontario3.5 15/ /416 Milan2.8 8/ /299 Finland5.5 4/ /80 Sweden1.5 3/ /187 Range (%)

Learn More At: Techniques for Partial Breast Irradiation 3-D conformal external beam radiotherapy Multi-catheter brachytherapy Balloon catheter brachytherapy Intra-operative Radiotherapy

Learn More At: Multi-Catheter Brachytherapy

Learn More At: Multi-Catheter Brachytherapy

Learn More At: 3-D Conformal Irradiation Technique

Learn More At: Balloon Catheter Brachytherapy

Learn More At: IORT Veronesi et al: A preliminary report of IORT in limited stage breast cancers that are conservatively treated. Eur J Cancer Nov;37(17): Mobile linear accelerator 3-9 Mev eb Gy in 103 patient No complications

Learn More At: NSABP Protocol B-39 RTOG Protocol 0413 A randomized Phase III Study of Conventional Whole Breast Irradiation vs Partial Breast Irradiation for Women with Stage 0, I, II Breast Cancer

Learn More At: NSABP Dose Prescription 3D Conformal External Beam Radiotherapy Gy total dose at 3.85 Gy per fraction delivered twice daily in 10 fractions over 5 treatment days Multi-Catheter and Balloon catheter Brachytherapy 34 Gy total dose at 3.4 Gy per fraction delivered twice daily in 10 fractions over 5 treatment days

Learn More At: NSABP Target Volume for 3D-CRT patient motion The CTV is defined by expanding the excision cavity volume by 15 mm. The PTV includes a 10 mm expansion of the CTV to compensate for patient motion and variability of treatment set-up

Learn More At: Novel Techniques for Partial Breast Irradiation CyberKnife

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CyberKnife Approved by the FDA since 2001 Nearly 30,000 patients treated worldwide More than 200 peer review papers have been published More than 80 hospitals and medical centers provide CyberKnife technology

Learn More At: How is the technology different? Advanced interactive robotics Real-time imaging Dynamic automated motion tracking Flexible and accurate linac multiple-beam radiation delivery

Learn More At: Methods for tracking motion Skull and spine tracking: bony landmarks are tracked Fiducial tracking: radio-opaque marker are placed near soft tissue targets and tracked Respiratory tracking (Synchrony): with respiration, LED’s on the exterior of the patient are correlated with the movement of the target/tumor and fiducials

Learn More At: Fiducial Tracking Gold seeds 5.0 mm x mm

Learn More At: Respiratory Tracking Beam Off Beam On Treatment Field Gating Synchrony TM Treatment beam is turned on and off as tumor enters and exits a static treatment field Dynamic treatment field follows the tumor while the treatment beam is turned on = Over-treated healthy tissue

Learn More At: Accuracy When used properly, Synchrony™ provides a degree of accuracy of better than 1.5mm –Allows reduced planning margins for lesions that move with respiration Gating and breath holding require margins of 5-10mm to compensate for setup and targeting uncertainty

Learn More At: Cyberknife Demonstration

Learn More At: Cyberknife Beam Profile

Learn More At: Indications for Cyberknife Intracranial lesions: single fraction, or fractionated Head and neck: –Nasopharynx & base of skull, primary or recurrent –Other sites, as boost following conventional RT, or recurrent Spine: where surgery indicated but not feasible, and conventional RT less effective or not possible Lung: where surgery indicated but not feasible Liver: where surgery indicated but not feasible Pancreas: unresectable but localized tumors Kidney: where surgery indicated but not feasible Previously irradiated tumors: retreatment w/ conventional RT not possible, for severe symptoms, Karnofsky > 40

Learn More At: A phase II Study of CyberKnife Radiosurgery delivered to the Partial Breast for Women with Stage 0, I, II Breast Cancer Seattle CyberKnife

Learn More At: Primary and Secondary Aims of Study This study will evaluate the technical feasibility of PBI with the CyberKnife as well as evaluate QOL issues that relate to treatment side- effects, cosmetic outcomes and patient convenience

Learn More At: Patient Eligibility Stage 0, I, II non-lobular breast cancer Cancer must be ≤ 3 cm Surgical treatment must be a lumpectomy Margins must be > 2mm for both DCIS and invasive disease Negative sentinel Lymph node(s) or an axillary dissection Lumpectomy cavity must be clearly delineated

Learn More At: Justification of Radiosurgical Dose By applying the linear-quadratic cell survival model with an alpha-beta ratio of 4, a dose of 30 Gy given in 5 stages of 6 Gy between 5 to 10 days is radiobiologically equivalent in tumor control and late breast tissue complications as the whole breast doses used by NSABP

Learn More At: Partial Breast Planning for CyberKnife The CTV is the excision rim plus a 10 mm margin in all directions The PTV is defined as the CTV plus a 5mm margin The dose is will be delivered to the % isodose prescription line

Learn More At: Cyberknife PBI Treatment Volume

Learn More At: Cyberknife Radiosurgery for Early Breast Cancer: a pilot investigation to determine the feasibility of Synchrony imaging and fiducial identification for motion tracking Seattle Cyberknife Fresno Community Regional Medical Center

Learn More At: Protocol Objectives To determine if there is sufficient geometric stability of gold markers in the breast for Synchrony motion tracking To determine the optimal patient treatment position for Synchrony motion tracking

Learn More At: Seattle CyberKnife Summary Greater than 140 sites treated including primary tumors of the lung, brain, prostate and metastases to the lung, liver, brain and bone June 2007 to begin a breast pilot to determine the feasibility of Synchrony motion tracking January 2008 planned open enrollment for a multi-institutional PBI protocol using Cyberknife