Targeted Intraoperative Radiotherapy in Oncology

175 Pages·2014·9.926 MB·English

by  Mohammed Keshtgar, Katharine Pigott, Frederik Wenz (eds.)

Targeted
Intraoperative
Radiotherapy in
Oncology
Mohammed Keshtgar
Katharine Pigott
Frederik Wenz
Editors
123
Targeted Intraoperative Radiotherapy
in Oncology

Mohammed Keshtgar (cid:129) Katharine Pigott

Frederik Wenz
Editors
Targeted Intraoperative
Radiotherapy in

Oncology
Editors
Mohammed Keshtgar Frederik Wenz
Division of Surgery Department of Radiation Oncology
and Interventional Sciences University Medical Center Mannheim
Department of Breast Surgery University of Heidelberg
University College London Medical Mannheim
School; Royal Free London NHS Germany
Foundation Trust
Hampstead
UK
Katharine Pigott
Department of Clinical Oncology
Royal Free London Foundation
NHS Trust
London
UK
ISBN 978-3-642-39820-9 ISBN 978-3-642-39821-6 (eBook)
DOI 10.1007/978-3-642-39821-6
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2013955230
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Foreword
Targeted intraoperative radiotherapy was developed more than a decade ago
so that radiation was applied during operation targeted to the peri-tumoral
tissues. The technique was designed at University College London for breast
cancer and has through a randomized controlled trial disseminated all over
the world. The targeted intraoperative radiotherapy in oncology is the fi rst
reference textbook in this fi eld, edited by the pioneers of this technology. A
panel of multidisciplinary experts who have been involved with the TARGIT
technology for many years contributed to this book. It covers the scientifi c
background of this technology, including radiobiology, mechanism of action
and radiation safety aspects. It also provides a well-illustrated practical guid-
ance to clinicians from various disciplines involved in management in cancer.
It comprehensively covers the quality assurance and commissioning of the
equipments and also provides detailed information on how to use the system
in the operating room. The book also provides the latest updates on the results
of randomised controlled trials and all the literatures related to this technol-
ogy. The quality of life and health economics and cosmesis is also covered,
along with training requirements to introduce this innovative technology into
the health care system. Although the emphasis has been on breast cancer,
applications in other cancers including rectal, brain, head and neck and cervi-
cal cancers as well as its use in bone metastasis is discussed. We congratulate
the editorial team with an excellent review on this topic, which will alter the
management of patients with many solid tumors, especially breast cancer, in
the coming years.
Cornelis J.H. van de Velde
Department of Surgery
President European CanCer Organization (ECCO)
Brussels, Belgium
David Azria
Coordonnateur du pôle de Radiothérapie Oncologique
Président de la CME
ICM
Montpellier, France
v

Pref ace
O ver the past few decades, the major change in the management of early
breast cancer has been the shift towards less invasive approaches. These
include breast conservation surgery and sentinel lymph node biopsy.
Postoperative radiotherapy is regarded as an essential adjunct to BCS and
cannot be safely omitted. There is overwhelming evidence that this approach
decreases the risk of local recurrence and improves survival. The aim of
radiotherapy is to selectively kill any residual tumour cells without damaging
normal cells.
I t is important to remember that whole breast radiotherapy is not without
risks. Although treatment regimens have become safer with careful planning
using computed tomography and treatment delivery using tangential fi elds,
healthy tissues such as the heart, ribs and lungs do receive a small but signifi -
cant dose of radiation.
A lthough the recurrence rate in breast cancer is low, the results of many
clinical trials and observational studies have demonstrated that around 90 %
of local recurrences after BCS occur within the same quadrant of the breast
that harboured the primary tumour (index quadrant). This observation raises
the question of whether whole breast radiotherapy is necessary in all patients
and whether radiotherapy to the index quadrant of the breast alone would be
suffi cient. This has led to growing interest in accelerated partial breast irra-
diation (APBI), which aims to decrease the volume of breast treated and
increase the daily fraction size of radiation.
A Photon Radiosurgery System (PRS) was fi rst introduced at the London
Royal Free Hospital in 1995 to assess its role in the treatment of solitary brain
metastases. The tip of the probe was placed into the tumour, using standard
stereotactic techniques, allowing for the delivery of a prescribed therapeutic
radiation dose directly into the centre of the metastasis. Subsequently, the
system was trialed for the fi rst time in treatment of primary breast cancer at
the University College London after the design and development of polymer
applicators of various diameters to insert into the tumour cavity after
resection.
In March 2000, an international, phase 3 randomised controlled trial in
early breast cancer was launched as a non-inferiority trial and enrolled over
3,400 patients from 33 centres in eleven countries. The trial results indicate
that the TARGIT technique using IntrabeamT M is safe and the effi cacy falls
within the pre-specifi ed non-inferiority margin of 2.5 % for local recurrence
vii
viii Preface
as compared to external beam radiotherapy. Subsequently this technique was
used for other solid tumours which is at various stages of development.
T ARGIT Academy was subsequently established in 2010 to ensure appro-
priate introduction of this new technology into routine clinical practice. The
focus of the Academy is on quality assurance and high standards in clinical
education and training. It runs regular training courses in London and Mannheim
and offers high-quality hands-on training and provides a networking platform
which enables interaction and cooperation between surgeons, radiation oncolo-
gists, medical physicists and the extended multidisciplinary team.
T his book is prepared by a panel of multidisciplinary experts who have
been involved with the TARGIT technology from the outset. The purpose of
this book is to provide a practical guide to clinicians from various disciplines
who treat cancer patients. Although the emphasis is on breast cancer, how-
ever we have included the experience in brain tumours, rectal cancer and
spinal metastases. We have presented case histories to enhance the learning
points. We hope that you fi nd this book a useful adjunct to your day-to-day
practice.
Hampstead, UK Mohammed Keshtgar
London, UK Katharine Pigott
Mannheim, Germany Frederik Wenz
Contents
1 Targeted Intraoperative Radiotherapy: Concept and Review
of Evidence in Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Mohammed Keshtgar and Frederik Wenz
2 Mechanism of Action of TARGIT . . . . . . . . . . . . . . . . . . . . . . . . 7
Gustavo Baldassarre, Barbara Belletti, Mario Mileto,
and Samuele Massarut
3 How to Use the INTRABEAM System . . . . . . . . . . . . . . . . . . . . 13
Regina Gonzalez and Claire Reynolds
4 Quality Assurance and Commissioning . . . . . . . . . . . . . . . . . . . 31
Frank Schneider, Sven Clausen, and David J. Eaton
5 Radiation Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
David J. Eaton and Frank Schneider
6 Radiobiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Frederik Wenz, Katia Pasciuti, and Carsten Herskind
7 Surgical Aspects of the TARGIT Technique
in Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Mohammed Keshtgar
8 Follow-Up Findings in the Tumour Bed After IORT –
What the Radiologist Needs to Know . . . . . . . . . . . . . . . . . . . . . 67
Klaus Wasser and Elena Sperk
9 Quality of Life and Late Radiation Toxicity . . . . . . . . . . . . . . . . 71
Elena Sperk and Grit Welzel
10 Cosmetic Outcome Following TARGIT . . . . . . . . . . . . . . . . . . . 79
Norman R. Williams and Mohammed Keshtgar
11 Targeted Intraoperative Radiotherapy and Persistent
Pain After Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Kenneth Geving Andersen and Henrik Flyger
12 Other Applications of INTRABEAM® . . . . . . . . . . . . . . . . . . . . 93
Tina Reis, Elena Sperk, Yasser Abo-Madyan, Michael Ehmann,
Frederic Bludau, and Frederik Wenz
ix