Meme Koruyucu Cerrahi Sonrası (MKC) Simultane İntegre Boost (SIB) Tekniğinin Farklılığı

Öz

Meme koruyucu cerrahi (MKC) sonrası tüm meme ışınlaması erken evre meme kanseri için standart tedavidir. Erken evre meme kanseri için meme koruyucu cerrahi ve ardından postoperatif radyoterapi mastektomi kadar etkilidir. Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi Radyasyon Onkoloji kliniğine başvurmuş erken evre 10 meme kanserli hasta çalışmaya dahil edilmiştir. Çalışma retrospektif bir çalışma olup, hastalar çalışmalarda geçen plan ve tekniklerle tedavi edilmemiştir. Yapılan çalışmada meme kanseri nedeniyle meme koruyucu cerrahi uygulanmış hastalarda tüm meme ve boost alanına Sekansiyel Yoğunluk Ayarlı Radyoterapi (YART) ve Simultane İntegre ek (Boost) Yoğunluk Ayarlı Radyoterapi (SIB YART) teknikleri ile planlanan hedef alanı (PTV) ve risk altındaki organların (OAR) dozimetrik olarak karşılaştırılması amaçlanmaktadır. Çalışma için ardışık YART kullanılan hastalara tüm memeye 50 Gy/25 fraksiyon ve boost alanına 10 Gy/ 5 fraksiyon, SIB YART kullanılan hastalara da tüm memeye toplam 50,4 Gy/ 28 fraksiyon verilirken aynı zamanda boost hacmine ek doz 60 Gy/ 28 fraksiyon doz verilir. Aynı taraf akciğer, kalp, PTV meme ve PTV boost alanlarının minimum ve maksimum dozları ile Homojenite indeks (HI), konformite indeks (CI) değerleri eşleşmiş veriler için t – testi minitab programı yardımı ile alınan sonuçlar istatistiksel olarak değerlendirilmiştir.
SIB YART tekniği ile Ardışık YART tekniği aynı taraf akciğer; V5 değerinin 10 hasta için ortalama dozları karşılaştırıldığında sonuçlar istatistiksel olarak anlamlı değilken, V20 değeri 10 hasta için ortalama doz değeleri karşılaştırıldığında istatiksel olarak anlamlı olup SIB YART tekniği ile aynı taraf akciğer V20’de daha düşük doz ile tedavi gerçekleştirilebileceği ortaya konulmuştur. Kalp ortalama ve kalp V20 değerleri iki teknik için karşılaştırıldığında SIB YART tekniği istatistiksel olarak anlamlı bulunmamış olup, Ardışık YART tekniğine göre herhangi bir üstünlüğü yoktur. Tüm memede doz homojenitesi SIB YART ile daha iyi iken boost alanı homojenitesi ve tüm meme konformite indeksinde fark izlenmedi. Işınlanan fazla normal doku hacimlerini azaltmak, tedavi sürecini kısaltmak, risk altındaki organlarda doz azaltımı, meme için fraksiyon başına düşen dozu azaltmak ve akut cilt toksititesi insidansının düşük olması nedeniyle boost alanına fraksiyon başına dozu arttırmak için SIB YART tekniği, meme koruyucu RT'de standart kullanım için önerilebilinir.

Anahtar Kelimeler

• Meme Kanseri,Simultane İntegre Boost,Yoğunluk Ayarlı Radyotaerapi (YART),Meme Koruyucu Cerrahi

Difference of Simultaneous Integrated Boost Technique after Breast Conserving Surgery

Öz

Whole breast irradiation after breast conserving surgery (BCS) is the standard treatment for early stage breast cancer. For early-stage breast cancer, breast-conserving surgery and subsequent postoperative radiotherapy are as effective as mastectomy. An early stage 10 breast cancer patient admitted to the Radiation Oncology Clinic of Sisli Hamidiye Etfal Training and Research Hospital was included in the study. The study is a retrospective study and patients were not treated with the plans and techniques used in the studies. In the study, the planning target volume (PTV) and the organs at risk (OAR) planned with Sequential Intensity Modulated Radiotherapy (IMRT) and Simultaneous Integrated Supplement (Boost) Intensity Modulated Radiotherapy (SIB IMRT) techniques in patients who have undergone breast conserving surgery due to breast cancer. It is aimed to be compared dosimetrically. For the study, patients with consecutive IMRT were given 50 Gy / 25 fraction to the whole breast and 10 Gy / 5 fraction to the boost area, while patients with SIB IMRT were given a total of 50.4 Gy / 28 fractions to the entire breast, while additional dose to the boost volume was given 60 Gy / 28 fraction dose. Ipsilateral lung, heart, the minimum and maximum doses of the PTV breast and PTV boost areas and the homogeneity index (HI), conformity index (CI) values were matched with the help of the t - test minitab program.

SIB IMRT technique and Sequential IMRT technique the ipsilateral lung; When the average doses of V5 value for 10 patients are compared, the results are not statistically significant, while the V20 value is statistically significant when the average dose values for 10 patients are compared, it has been demonstrated that SIB IMRT technique can be performed with a lower dose in the ipsilateral lung V20. When the heart average and heart V20 values are compared for the two techniques, the SIB IMRT technique was not statistically significant, and it has no superiority over the Sequential IMRT technique. While dose homogeneity was better with SIB IMRT in whole breasts, there was no difference in boost area homogeneity and whole breast conformity index SIB IMRT technique for decreasing excess normal tissue volumes irradiated, shortening the treatment process, dose reduction in organs at risk, reducing the dose per fraction for the breast and increasing the dose per fraction to the boost area due to the low incidence of acute skin toxicity, standard use in breast protector RT it can be recommended for.

Anahtar Kelimeler

• Breast cancer,Simultaneous integrated boost,Intensity modulated radiotherapy (IMRT),Breast conserving surgery

Teşekkür

Our work has been done within the framework of academic ethical principles and the ethics committee permission has been obtained under the number 1322.

Kaynakça

1. Alford, S. L., Prassas, G. N., Vogelesang, C. R., Leggett, H. J. & Hamilton, C. S. (2013). Adjuvant breast radiotherapy using a simultaneous integrated boost: clinical and dosimetric perspectives. J Med Imaging Radiation Oncology, 57(2), 222–9. https://doi.org/10.1111/j.1754-9485.2012.02473.
2. Bantema-Joppe, E. J., van der Laan, H. P., de Bock G. H., Wijsman, R., Dolsma, W. V. & Busz, D. M. (2011). Three-dimensional conformal hypofractionated simultaneous integrated boost in breast conserving therapy: results on local control and survival. Radiother Oncology, 100(2), 215–20. https://doi.org/10.1016/j.radonc.2011.05.027.
3. Bantema-Joppe, E. J., Schilstra, C., de Bock, G. H., Dolsma, W. V., Busz, D. M. & Langendijk, J. A.(2012). Simultaneous integrated boost irradiation after breast-conserving surgery: physician-rated toxicity and cosmetic outcome at 30 months’ followup. Int J Radiat Oncol, Biol, Phys., 83(e), 471–7. https://doi.org/10.1016/j.ijrobp.2012.01.050.
4. Bantema-Joppe, E. J., Vredeveld, E. J., de Bock, G. H., Busz, D. M., Woltman-van Iersel, M. & Dolsma, W. V. (2013). Five year outcomes of hypofractionated simultaneous integrated boost irradiation in breast conserving therapy; patterns of recurrence. Radiotherapy Oncology,108(2), 269–72. https://doi.org/10.1016/j.radonc.2013.08.037.
5. Bantema-Joppe, E. J., van der Laan, H. P. & Bock, G. H. (2011) Three-dimensional conformal hypofractionated simultaneous integrated boost in breast conserving therapy: Results on local control and survival. Radiotherapy and Oncology, 100(2), 215–220. https://doi.org/10.1016/j.radonc.2011.05.027.
6. Bartelink, H., Horiot, J. C., Poortmans, P. M., Struikmans, H., Van den Bogaert, W. & Fourquet, A. (2007). Impact of a higher radiation dose on local control and survival in breast-conserving therapy of early breast cancer: 10-year results of the randomized boost versus no boost EORTC 22881–10882 trial. J Clinic Oncology, 25(22), 3259–65.
7. Cendales, R., Vasquez, J., Arbelaez, J. C., Bobadilla, I., Espanol, R. & Torres, F. (2012). Intensity modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB) in a patient with left breast cancer and pectus excavatum. Clin Transl Oncology, 14(10), 747–54. https://doi.org/10.1007/s12094-012-0862-7.
8. Chao, K. S, Perez C. A. & Brady L. W. (2004). Radyasyon Onkolojisi Tedavi Kararları. Nobel Tıp Kitabevleri, İstanbul, Turkey.

9. Claus, F., Mijnheer, B., Rasch, C. & Bortfeld, T. (2002) Report of a study on IMRT planning strategies for ethmoid sinus cancer. Strahlenther Onkol 178, 572- 576.
10. Collette, S., Collette, L., Budiharto, T., Horiot, J. C., Poortmans, P. M. & Struikmans, H. (2008). Predictors of the risk of fibrosis at 10 years after breast conserving therapy for early breast cancer: a study based on the EORTC Trial 22881–10882 ‘boost versus no boost’. Eur J Cancer, 44(17), 2587–99. https://doi.org/10.1016/j.ejca.2008.07.032.
11. Cuzick, J., Stewart, H., Peto, R. & Houghton, J. (1994). Cause Spesific Mortality in Long Term Survivors of Breast Cancer Who Participated in Trials of Radiotherapy. J Clin Oncol, 12, 447-53.
12. Fowler, J. F. (1989).The linear-quadratic formula and progress in fractionated radiotherapy. BrJ Radiol, 62, 679-694.
13. Guerrero, M., Li X. A., Earl, M. A., Sarfaraz, M. & Kiggundu, E. (2004). Simultaneous integrated boost for breast cancer using IMRT: a radiobiological and treatment planning study. Int J Radiat Oncol, Biol, Phys., 59(5), 1513–22.
14. Haydaroglu, A. (2015) Meme Kanseri Epidemiyoloji, Sınıflama Ve Evreleme. Epidemiology, Classification and Staging of Breast Cancer. Türkiye Klinikleri J Radiat Oncol-Special Topics. 1(2), 1-6.
15. Haydaroğlu, A., (2014). Meme Kanserinde Modern Radyoterapi Uygulamaları, Ege Üniversitesi Yayınları, İzmir, Turkey. Hijal, T., Fournier-Bidoz, N., Castro-Pena, P., Kirova, Y. M., Zefkili, S. & Bollet, M. A. (2010). Simultaneous integrated boost in breast conserving treatment of breast cancer: a dosimetric comparison of helical tomotherapy and threedimensional conformal radiotherapy. Radiother Oncol.;94(3), 300-6. https://doi.org/10.1016/j.radonc.2009.12.043.
16. International Comission on Radiation Units and Measurements (1999) Report 62 Prescribing, Recording and Reporting Photon Beam Therapy (Supplement to ICRU Report 50).
17. International Commission of Radiation Units and Measurements, (1999) Report 62. Prescribing, recording, and reporting photon beam therapy (supplement to ICRU Report 50).
18. International Commission of Radiation Units and Measurements, (2010) Report 83. Prescribing, recording, and reporting intensity-modulated photon-beam therapy (IMRT).
19. Kanyılmaz, G., Aktan, M., Benli Yavuz, B. & Koç, M. (2017) Meme Kanserinde 5 Yıllık Tedavi Sonuçlarımız ve Prognostik Faktörler. Tek Merkez Deneyimi. Selçuk Tıp Dergisi, 33(1), 5-9.
20. Khan, F. M. (2003). The Physics of Radiation Therapy, 3rd Edition, Baltimore: Lippincott Williams and Wilkins.
21. Kozan, R. & Tokgoz, V. (2016) Türkiye'de Meme Kanseri Farkındalığı ve Tarama Programı. Acıbadem Üniversitesi Sağlık Bilimleri Dergisi, 7 (4), 185-188.
22. Moamen M. O .M., Gerhard G., Lennart J., Frederik W., & Yasser A. (2015). M.Comparison of breast simultaneous integrated boost (SIB) radiotherapy techniques. Radiation Oncology, 10-139.
23. Moamen M. O., Yasser, A. M., Lennart, J., Frederik, W. & Gerhard, G. (2016). Comparison of breast sequential and simultaneous integrated boost using the biologically effective dose volüme histogram Aly. Radiation Oncology, 11-16.
24. Mundt, A. J. & Roeske, J. C. (2005) Intensity Modulated Radiation Therapy: A Clinical Perspective, BC Decker Inc.
25. Nicolini, G., Clivio, A., Fogliata, A., Vanetti, E. & Cozzi L. (2009). Simultaneous integrated boost radiotherapy for bilateral breast: a treatment planning and dosimetric comparison for volumetric modulated arc and fixed field intensity modulated therapy. Radiat Oncology, 4-27. https://doi.org/10.1186/1748-717X-4-27.
26. Sedlmayer, F., Sautter-Bihl, M. L., Budach, W., Dunst, J., Feyer, P., Fietkau, R., Haase, W., Harms, W., Rödel, C., Souchon, R., Wenz, F. & Sauer R, (1994). Is the simultaneously integrated boost (SIB) technique for early breast cancer ready to be adopted for routine adjuvant radiotherapy. Strahlentherapie und Onkologie, 189, 193-196.
27. Scorsetti, M., Alongi, F., Fogliata, A., Pentimalli, S., Navarria, P. & Lobefalo, F. (2012). Phase I-II study of hypofractionated simultaneous integrated boost using volumetric modulated arc therapy for adjuvant radiation therapy in breast cancer patients: a report of feasibility and early toxicity results in the first 50 treatments. Radiation Oncology, 7 -145. https://doi.org/10.1186/1748-717X-7-145.
28. Thomas, J. & Fitzgerald, M. D. (2004). Marcia Urie, Forward-planned, multiple-segment, tangential fields with concomitant boost in the treatment of breast cancer. Med.Dosim, 29(4), 265–270.
29. Van Der Laan, H. P., Dolsma, W., Maduro, J. H., Korevaar, E. W., Hollander, M. & Langendijk, J. A. (2007). Tree-dimensional conformal simultaneously integrated boost technique for breastconserving radiotherapy. International Journal of Radiation Oncology Biology Physics, 68(4), 1018–1023.
30. Van Parijs, H., Miedema, G., Vinh-Hung, V., Verbanck, S., Adriaenssens, N. & Kerkhove, D. (2012). Short course radiotherapy with simultaneous integrated boost for stage I-II breast cancer, early toxicities of a randomized clinical trial. Radiation Oncology, 1, 7-80. https://doi.org/10.1186/1748-717X-7-80.
31. Van Parijs, H., Reynders, T., Heuninckx, K., Verellen, D., Storme, G. & De Ridder, M. (2014). Breast conserving treatment for breast cancer: dosimetric comparison of different non-invasive techniques for additional boost delivery. Radiation Oncology, 9:36. https://doi.org/10.1155/2014/827475.
32. Webb, S. (2003). The physical basis of IMRT and inverse planning. Br J Radiology, 76(910): 678-689.
33. World Health Organization. (2016). What Is Breast Cancer, https://www.cancer.org/cancer/breast-cancer/about/what-is-breast-cancer.html, Erişim tarihi: 03.07.2017.