Accelerated Partial Breast Irradiation: Using the CyberKnife as the Radiation Delivery Platform in the Treatment of Early Breast Cancer

Sandra Vermeulen, Cristian Cotrutz, Astrid Morris, Robert Meier, Claire Buchanan, Patricia Dawson, Bruce Porter, Sandra Vermeulen, Cristian Cotrutz, Astrid Morris, Robert Meier, Claire Buchanan, Patricia Dawson, Bruce Porter

Abstract

We evaluate the CyberKnife (Accuray Incorporated, Sunnyvale, CA, USA) for non-invasive delivery of accelerated partial breast irradiation (APBI) in early breast cancer patients. Between 6/2009 and 5/2011, nine patients were treated with CyberKnife APBI. Normal tissue constraints were imposed as outlined in the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 (NSABP/RTOG) Protocol (Vicini and White, 2007). Patients received a total dose of 30 Gy in five fractions (group 1, n = 2) or 34 Gy in 10 fractions (group 2, n = 7) delivered to the planning treatment volume (PTV) defined as the clinical target volume (CTV) +2 mm. The CTV was defined as either the lumpectomy cavity plus 10 mm (n = 2) or 15 mm (n = 7). The cavity was defined by a T2-weighted non-contrast breast MRI fused to a planning non-contrast thoracic CT. The CyberKnife Synchrony system tracked gold fiducials sutured into the cavity wall during lumpectomy. Treatments started 4-5 weeks after lumpectomy. The mean PTV was 100 cm(3) (range, 92-108 cm(3)) and 105 cm(3) (range, 49-241 cm(3)) and the mean PTV isodose prescription line was 70% for groups 1 and 2, respectively. The mean percent of whole breast reference volume receiving 100 and 50% of the dose (V(100) and V(50)) for group 1 was 11% (range, 8-13%) and 23% (range, 16-30%) and for group 2 was 11% (range, 7-14%) and 26% (range, 21-35.0%), respectively. At a median 7 months follow-up (range, 4-26 months), no acute toxicities were seen. Acute cosmetic outcomes were excellent or good in all patients; for those patients with more than 12 months follow-up the late cosmesis outcomes were excellent or good. In conclusion, the lack of observable acute side effects and current excellent/good cosmetic outcomes is promising. We believe this suggests the CyberKnife is a suitable non-invasive radiation platform for delivering APBI with achievable normal tissue constraints.

Keywords: CyberKnife; accelerated partial breast irradiation; breast cancer; cosmesis.

Figures

Figure 1
Figure 1
Example of MRI images and image fusion. (A) T2* gradient-echo MRI image, yellow arrow denotes the fiducial markers. (B) STIR MRI image showing resection cavity. (C,D) Axial and sagittal fused images.
Figure 2
Figure 2
CyberKnife treatment planning images for a patient in the 34-Gy dose group. (A) Illustration of beam trajectories and (B) axial treatment planning image illustrating the omission of high doses to the chest wall and skin. Shown in (B) are three isodose lines at the 70, 50, and 30%. The green contour represents the planning target volume.
Figure 3
Figure 3
Pre- and post-CyberKnife APBI mammograms. (A) A left breast mammogram showing a biopsy clip in the tumor on a left lateral medial (LLM) view. (B) A left medial lateral oblique view of the same patient taken 14 months after CyberKnife APBI showing four gold fiducials (round opaque makers) and three titanium clips. The patient did not have chemotherapy or hormonal therapy post-treatment.

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