Parsiyel Meme Işınlamasında Cyberknife Sisteminde Farklı Kolimatörlerle Elde Edilen Stereotaktik Meme Radyoterapisi Sanal Planlarının Karşılaştırılması: Retrospektif Çalışma

Öz

Çalışmamızda erken evre meme kanseri tanılı hastalarda hızlandırılmış kısmı meme ışınlamasında (HKMI) CyberKnife (CK) tedavi cihazında yapılan sanal planlarda hedef hacim ve kritik organ dozlarının karşılaştırılması amaçlanmıştır. Birimimizde radyoterapi almış 5 hasta için CyberKnife sisteminde Iris, sabit ve çok yapraklı kolimatör (ÇYK) için günlük 6 Gy toplam 30 Gy olacak şekilde sanal plan oluşturuldu. Üç farklı kolimatör için dozimetrik parametreler NSABP-39/RTOG 0413 protokolündeki kısıtlamalara göre analiz edildi. Planlarda kritik organların korunması ve PTV’nin reçete edilen dozun % 95’ini alması sağlandı. Reçete edilen doz minimum % 80’lik izodoz eğrisine tanımlandı. Homojenite indeksi (Hİ), konformite indeksi (Kİ), tedavi süresi (dk), monitör unit (MU) ve kritik organların aldığı dozlar karşılaştırıldı. Iris, sabit kolimatör, ÇYK için sırasıyla Hİ değerleri ortalama 1,2- 1,2- 1,19, Kİ değerleri ortalama 1,08- 1,06- 1,07 tedavi süresi ortalama 47,6- 52,2- 25,4 (dk) ve MU değerleri ortalama 19736,2- 20267,3- 7161,3 olarak bulunmuştur. Planların karşılaştırılması sonucunda MU, tedavi süresi için anlamlı fark bulunmuştur (p< 0,05). Ortalama MU ve tedavi süresi, en düşük ÇYK’da bulunmuştur Hİ, Kİ için anlamlı fark bulunmamıştır. Aynı taraf memenin V30 ve V15 değerleri en düşük ÇYK’da çıkmıştır. Akciğer ve kalp için Dmax değerleri arasında anlamlı bir fark bulunmadı. Sonuç olarak, hedef hacim her kolimatörde istenen dozu almıştır. Karşı meme ve karşı akciğer dozları en düşük Iris’te bulundu. Kalp dozları için sabit kolimatörün daha uygun olduğu bulundu. Fakat bu değerler anlamlı olarak fark yaratmadı. Sabit kolimatörde (52,2 dk), tedavi süresi uzun olduğu için klinik uygulamalarda zorluk çıkarabilir. CyberKnife ile meme SBRT uygulamalarında kolimatör seçimi, tümör boyutu, kritik organlara yakınlık durumu ve tümör lokalizasyonuna bağlı olarak değişebilir.

Anahtar Kelimeler

• VMAT
• ÇYK
• CYBERKNIFE
• HKMI

Comparison of Stereotactic Body Radiotherapy Virtual Plans Obtained with Different Colimators in Cyberknife System in Partial Breast Irradiatıon: Retrospective Study

Öz

In our study, it was aimed to compare the volume of accelerated partial breast irradiation in patients diagnosed with early stage breast cancer in CyberKnife target and volume targeted virtual plans (APBI). A virtual plan was created in CyberKnife system for 5 patients who received radiotherapy in our unit, 6 Gy per day for Iris, fixed and multi-leaf collimator (MLC) and 30 Gy in total. Dosimetric parameters for three different collimators were analyzed according to the constraints of the NSABP-39/RTOG 0413 protocol. In the plans, it was ensured that critical organs were protected and PTV received 95% of the prescribed dose. The prescribed dose was defined by a minimum 80% isodose curve. Homogeneity index (HI), conformity index (CI), treatment time (min), monitor unit (MU) and doses received by critical organs were compared. The mean HI values for iris, fixed collimator, and MLC were 1.2- 1.2- 1.19, mean CI values were 1,08-1,06-1,07, mean treatment time was 47,6- 52,2- 25,4 (min) and MU values were found to be 19736,2-2026,.3- 7161,3 on average. Mean MU and duration of treatment were found in the lowest MLC. No significant difference was found for HI, CI. As a result of the comparison of the plans, a significant difference was found for MU and duration of treatment (p< 0,05).ipsilateral breast30 and V15 were found at the lowest MLC.for lung and heartDmax was no significant difference between. As a result, the target volume received the desired dose in each collimator. The contralateral breast and contra-lateral lung doses were the lowest in Iris. Fixed collimator was found to be more suitable for cardiac doses. But these values did not make a significant difference. In the fixed collimator (52,2 min), it may cause difficulties in clinical applications due to the long treatment time. The choice of collimator in breast SBRT applications with CyberKnife may vary depending on tumor size, proximity to critical organs and tumor localization.

Anahtar Kelimeler

• VMAT
• APBI
• MLC
• CYBERKNİFE

Kaynakça

1. 1. Harbeck, N., Penault-Llorca, F., Cortes, et al. (2019). Breast cancer. Nat Rev Dis Primers, 5(1), 66.
2. 2. Lazovich, D., Solomon, C. C., Thomas, D. B., Moe, R. E., White, E. (1999). Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. Cancer, 86 (4), 628-637.
3. 3. Clarke, M., Collins, R., Darby, S., et al. Early Breast Cancer Trialists' Collaborative, G. (2005). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet, 366 (9503), 2087-2106.
4. 4. Early Breast Cancer Trialists' Collaborative, G., Darby, S., McGale, P., Correa, et al. (2011). Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet, 378 (9804), 1707-1716.
5. 5. Nattinger, A. B., Hoffmann, R. G., Kneusel, R. T., Schapira, M. M. (2000). Relation between appropriateness of primary therapy for early-stage breast carcinoma and increased use of breast-conserving surgery. Lancet, 356 (9236), 1148-1153.
6. 6. Group, S. T., Bentzen, S. M., Agrawal, R. K., et al. (2008). The UK Standardisation of Breast Radiotherapy (START) Trial B of radiotherapy hypofractionation for treatment of early breast cancer: a randomised trial. Lancet, 371 (9618), 1098-1107.
7. 7. Whelan TJ, Pignol JP, Levine MN, et al. (2010). Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 362, 513–20.
8. 8. Touboul, E., Buffat, L., Belkacemi, Y., et al. (1999). Local recurrences and distant metastases after breast-conserving surgery and radiation therapy for early breast cancer. Int J Radiat Oncol Biol Phys, 43 (1), 25-38.

9. 9. Veronesi, U., Marubini, E., Del Vecchio, M., et al. (1995). Local recurrences and distant metastases after conservative breast cancer treatments: partly independent events. J Natl Cancer Inst, 87 (1), 19-27.
10. 10. Njeh, C. F., Saunders, M. W., Langton, C. M. (2010). Accelerated Partial Breast Irradiation (APBI): A review of available techniques. Radiat Oncol, 5, 90.
11. 11. Rault, E., Lacornerie, T., Dang, H. P., Crop, F., Lartigau, E., Reynaert, N., Pasquier, D. (2016). Accelerated partial breast irradiation using robotic radiotherapy: a dosimetric comparison with tomotherapy and three-dimensional conformal radiotherapy. Radiat Oncol, 11, 29.
12. 12. Grantzau, T., Overgaard, J. (2015). Risk of second non-breast cancer after radiotherapy for breast cancer: a systematic review and meta-analysis of 762,468 patients. Radiother Oncol, 114 (1), 56-65.
13. 13. Strnad, V., Ott, O. J., Hildebrandt, G., et al. (2016). 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet, 387 (10015), 229-238.
14. 14. Vaidya, J. S., Joseph, D. J., Tobias, J. S., et al. (2010). Targeted intraoperative radiotherapy versus whole breast radiotherapy for breast cancer (TARGIT-A trial): an international, prospective, randomised, non-inferiority phase 3 trial. Lancet, 376 (9735), 91-102.
15. 15. Recht, A., Ancukiewicz, M., Alm El-Din, M. A.,et al. (2009). Lung dose-volume parameters and the risk of pneumonitis for patients treated with accelerated partial-breast irradiation using three-dimensional conformal radiotherapy. J Clin Oncol, 27 (24), 3887-3893.
16. 16. Benedict, S. H., Yenice, K. M., Followill, D., et al. (2010). Stereotactic body radiation therapy: the report of AAPM Task Group 101. Med Phys, 37 (8), 4078-4101.
17. 17. Hoekstra, N., Habraken, S., Swaak-Kragten, A., Pignol, J. P., Hoogeman, M. (2021). Fiducial marker motion relative to the tumor bed has a significant impact on PTV margins in partial breast irradiation. Radiother Oncol, 163, 1-6.
18. 18. Ciervide, R., Montero, A., Potdevin, G., et al. (2021). 5-year results of accelerated partial breast irradiation (APBI) with SBRT (stereotactic body radiation therapy) and exactrac adaptive gating (Novalis((R))) for very early breast cancer patients: was it all worth it? Clin Transl Oncol, 23 (11), 2358-2367.
19. 19. CK – 028096 – TRK. CyberKnife ® Tedavi Uygulama Kılavuzu.
20. 20. Hoogeman, M., Prevost, J. B., Nuyttens, J., Poll, J., Levendag, P., Heijmen, B. (2009). Clinical accuracy of the respiratory tumor tracking system of the cyberknife: assessment by analysis of log files. Int J Radiat Oncol Biol Phys, 74 (1), 297-303.
21. 21. Wong, K. H., Dieterich, S., Tang, J., Cleary, K. (2007). Quantitative measurement of CyberKnife robotic arm steering. Technol Cancer Res Treat, 6 (6), 589-594.
22. 22. Baglan, K. L., Sharpe, M. B., Jaffray, D., et al. (2003). Accelerated partial breast irradiation using 3D conformal radiation therapy (3D-CRT). Int J Radiat Oncol Biol Phys, 55 (2), 302-31.
23. 23. Tosun, M., K. Çetintaş, S., Kılıç, H., ark. (2021). CyberKnife sisteminde Iris ve MLC tabanlı kolimatörler için beyin metastazlı olgularda SRT tedavi planlarının dozimetrik karşılaştırılması. Uludağ Üniversitesi Tıp Fakültesi Dergisi, 431-437.
24. 24. NSABP B-39, RTOG 0413: A Randomized Phase III Study of conventional whole breast irradiation versus partial breast irradiation for women with stage 0, I, or II breast cancer. (2006). Clin Adv Hematol Oncol, 4 (10), 719-721.
25. 25. Kılıç, H.M., Tosun, M., K. Çetintaş, S., ark. (2021). Erken Evre Meme Kanserli Hastalarda Hızlandırılmış Kısmi Meme Işınlamasında VMAT-CyberKnife Sanal Tedavi Planlarının İncelenmesi, Uludağ Üniversitesi Tıp Fakültesi Dergisi, 47 (3), 357-364.
26. 26. Bilge, H., Çetingöz, R., Garipoğlu, M., ark. (2013). Planların Değerlendirilmesi, Temel ve Klinik Radyoterapi, Hürriyet Matbaa, 82-83.
27. 27. Taylor, C. W., McGale, P., Povall, J. M., et al. (2009). Estimating cardiac exposure from breast cancer radiotherapy in clinical practice. Int J Radiat Oncol Biol Phys, 73 (4), 1061-1068.
28. 28. Lee , C.Y., Kim, W.C., Kim, H.J., Lee, J., Park, S., Huh, H.D. (2018). Dosimetric plan comparison of accelerated partial breast irradiation (APBI) Using CyberKnife. Prog Med Phys, 29, 73-80.
29. 29. Goggin, L. M., Descovich, M., McGuinness, C., Shiao, S., Pouliot, J., Park, C. (2016). Dosimetric Comparison Between 3-Dimensional Conformal and Robotic SBRT Treatment Plans for Accelerated Partial Breast Radiotherapy. Technol Cancer Res Treat, 15 (3), 437-445.
30. 30. Lozza, L., Fariselli, L., Sandri, M., et al. (2018). Partial breast irradiation with CyberKnife after breast conserving surgery: a pilot study in early breast cancer. Radiat Oncol, 13(1), 49.
31. 31. Vermeulen, S. S., Haas, J. A. (2014). CyberKnife stereotactic body radiotherapy and CyberKnife accelerated partial breast irradiation for the treatment of early breast cancer. Translational Cancer Research, 3 (4), 295-302.
32. 32. Herein, A., Stelczer, G., Pesznyak, C., et al. (2021). Multicatheter interstitial brachytherapy versus stereotactic radiotherapy with CyberKnife for accelerated partial breast irradiation: a comparative treatment planning study with respect to dosimetry of organs at risk. Radiol Oncol, 55(2), 229-239.