1. Learn More At: www.DoctorVermeulen.com 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

2. Learn More At: www.DoctorVermeulen.com 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

3. Learn More At: www.DoctorVermeulen.com 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

4. Learn More At: www.DoctorVermeulen.com 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.

5. Learn More At: www.DoctorVermeulen.com 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

6. Learn More At: www.DoctorVermeulen.com Radiation Therapy Machines produce energy from the Electromagnetic Spectrum - Linear Accelerator - CyberKnife - Gamma Knife Radiation Therapy Machines

7. Learn More At: www.DoctorVermeulen.com 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

8. Learn More At: www.DoctorVermeulen.com 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)

9. Learn More At: www.DoctorVermeulen.com 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

10. Learn More At: www.DoctorVermeulen.com 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

11. Learn More At: www.DoctorVermeulen.com In 1992, the American College of Surgery reported that only 10-40% of eligible candidates for conservative surgery followed by radiation therapy received it

12. Learn More At: www.DoctorVermeulen.com Breast Conservation Therapy Treatment Objectives Acceptable cosmesis Local control of disease Minimal treatment complications

13. Learn More At: www.DoctorVermeulen.com 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

14. Learn More At: www.DoctorVermeulen.com External Beam Radiotherapy Treatment Option Linear AcceleratorExternal Beam Treatment Plan

15. Learn More At: www.DoctorVermeulen.com 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

16. Learn More At: www.DoctorVermeulen.com Whole Breast Radiation Side Effects Acute Side Effects Fatigue Skin changes Chronic Side Effects Pneumonitis Lymphedema Rib Fracture Secondary Malignancy Skin Changes Pericarditis

17. Learn More At: www.DoctorVermeulen.com 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

18. Learn More At: www.DoctorVermeulen.com Advantages of Partial Breast Irradiation Over Whole Breast Treatment Decrease time and inconvenience Decrease acute and chronic toxicity Improved radiation therapy underutilization

19. Learn More At: www.DoctorVermeulen.com 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

20. Learn More At: www.DoctorVermeulen.com 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)

21. Learn More At: www.DoctorVermeulen.com Techniques for Partial Breast Irradiation Intraoperative Radiotherapy 3-D Conformal External Beam Radiotherapy Multicatheter Brachytherapy Balloon Catheter Brachytherapy

22. Learn More At: www.DoctorVermeulen.com 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

23. Learn More At: www.DoctorVermeulen.com Treatment Post-removal54 month F/U Multi-Catheter Brachytherapy

24. Learn More At: www.DoctorVermeulen.com Balloon Catheter Brachytherapy Advantages Over Other Types of PBI Techniques Short MD learning curve Improved target volume coverage Better patient tolerance Few complications

25. Learn More At: www.DoctorVermeulen.com Complications of Partial Breast Irradiation 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.

26. Learn More At: www.DoctorVermeulen.com Variable 4 to 5 cm balloon Multilumen, silicone catheter Radiation source port pathway Inserted obturator to prevent bending or coiling of the catheter shaft Needleless injection site Learn More At: www.DoctorVermeulen.com

27. MammoSite Procedure Lumpectomy cavity is created Trocar used to create pathway to cavity Un-inflated MammoSite is advanced into the cavity through the Trocar path MammoSite is inflated with saline/contrast to position the tissue to receive radiation therapy Design allows the 192 Ir Source to be centrally positioned within the applicator The 192 Ir source is advanced into the MammoSite and radiation therapy is delivered per the treatment plan

28. Learn More At: www.DoctorVermeulen.com 3-Dimensional rendering of applicator surface CT Image of Balloon Catheter

29. Learn More At: www.DoctorVermeulen.com 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 daysPost 5 months

30. Learn More At: www.DoctorVermeulen.com 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?

31. Learn More At: www.DoctorVermeulen.com We are on the continued quest of study to harness the benefits of energy produced by the Electromagnetic Spectrum Conclusion