10 Feb
Challenging Cases

Accelerated Breast Cancer Radiation Therapy

Dr Vineeta Goel, Director, Radiation Oncology, Fortis Hospital, Shalimar Bagh

Breast cancer treatment has undergone considerable evolution in last many year and has significantly improved survival for patients.

Breast cancers are treated with combination of surgery, chemotherapy, radiation therapy (RT) and sometimes hormonal therapy.

Radiation therapy is an essential treatment for breast cancer as it reduces the chance of local re-occurrence of cancer in breast. Patients who are treated with radiation therapy for breast cancer are also known to live/survive longer.

Traditionally, radiation therapy is given 5 days a week over 4 -5 weeks.

In recent past, there have been several technological advances in breast cancer radiation therapy. One of these advances is called accelerated partial breast irradiation (APBI).

APBI is used for selected women with early localized breast cancer. In this nylon catheters/tubes are placed around tumor bed during breast cancer surgery (Picture 1). Two to three days after surgery, radiation therapy is started to tumour bearing area/bed. This radiation therapy is given twice daily over 4 consecutive days using catheters placed at the time of surgery with HDR Brachytherapy machine (Picture 2). Several scientific studies have confirmed that APBI is as effective and safe as 4-5 weeks of RT in selected patients.

Picture 1- Brachytherapy catheters placed around tumour bed intraoperatively

Picture 2- Women receiving APBI with HDR Brachytherapy

APBI has several advantages

  1. Much shorter treatment time (4 days with APBI compared with 4-5 weeks normally).
  2. Much lesser radiation dose to lungs and heart.
  3. APBI is a very precise form of RT.

APBI is the way to go for safe delivery of RT with significantly shorter duration of treatment.

10 Feb
Challenging Cases

Stereotactic Radiation Therapy For Brain Metastases

Case 1 -Single Brain Metastases

A 55 Years old lady was diagnosed with left breast cancer in August 2015. She was treated with breast surgery, chemotherapy, radiation therapy and hormonal therapy.

She remained disease free for 3 years. In October 2018, she had an episode of seizure. Contrast MRI Brain showed 1.5×1.4 x1.6 cm enhancing lesion in left posterior frontal region of brain with mild surrounding edema suggestive of solitary brain metastases. (Figure 1) MR Spectroscopy showed intense choline peak with reduced NAA suggestive of mitotic etiology. Patient also underwent FDG whole body PET CT scan which showed that brain was the only site of metastases.

Figure 1- Brain MRI – Contrast T1 Sequence showing 1.5×1.4 x1.6 cm intensely enhancing nodule in left posterior frontal region with mild surrounding edema

Management

Neurosurgical resection of brain lesion was ruled out in view of location in close vicinity of motor and speech area.

She was then treated with stereotactic brain radiation therapy. He head was fixed in a non- invasive frame/mould. Radiation therapy (RT) was delivered in 3 fractions/sittings over 3 days using stereotactic radiosurgery (SRS) technique under image guidance. (Figure 2 and 3)

After brain radiosurgery, her hormonal treatment was changed in form of another pill. She was not given chemotherapy as her previous breast cancer was hormone receptor positive.

Figure 2 and 3 – RT planning CT Scan showing SRS dose distribution in axial and coronal views

Follow up

Post brain SRS, patient has a follow up of close to 2 years and she is disease free. She has no neurological deficit and she continues to be on hormonal treatment.

Case 2 –Multiple  Brain Metastases

Mr NK, 54 years old gentleman from Kashmir, diagnosed case of metastatic renal cell carcinoma presented to us at the beginning of Corona pandemic with complaints of weakness of right and upper limb.

Clinically he was well preserved except for grade 3 power in right and upper limbs suggestive of right hemiparesis.

His MRI Brain showed total 10 SOLs in brain suggestive of metastases and largest was 1.2 cm in diameter and was causing hemiparesis. (Figure 4)

Figure 4 – Multiple brain metastases as seen on MRI Brain

We treated all his brain lesions with SRS delivered over 3 days and avoided whole brain radiation therapy. (Figure 5 &6)

Immediate after radiation therapy his power on right side improved to 4/5. Since it was a short treatment done over only 3 days, he could go back to Kashmir safely.

Figure 5 and 6 – SRS beam arrangement and dose distribution

Discussion

Till few years back standard treatment of brain metastases was whole brain radiation therapy (WBRT). A new standard of care for brain metastases is to give focal stereotactic radiation therapy. There are several advantages of SRS over WBRT including short treatment, better local control of metastases, no neurocognition decline and no hair loss.

10 Feb
Challenging Cases

Radiation Therapy For (Left) Breast Cancer With Cardiac / Heart Protection

Breast Cancer is one of the most common cancers among women. Good news is, that many more patients today are long term breast cancer “survivors” with good quality of life because of advances in treatment.

Standard local treatment for breast cancer includes mastectomy or breast conservation surgery followed by chemotherapy and radiation therapy (RT).

Radiation therapy is an essential part of breast cancer treatment as it has been shown to decrease re – occurrence of cancer in breast/chest as well as improve survival rates of patients.

In radiation therapy for left breast cancer, there has always been big concern about safety of radiation doses to heart.

Fortunately, radiation therapy techniques have improved markedly in last few years with special attention to make it more focused and precise to decease its side effects.

Department of Radiation Oncology at Max Super specialty hospital, Shalimar Bagh, is a comprehensive department equipped with latest high end equipments like TrueBeam STx Linear Accelerator, 4 D CT simulator and HDR Brachytherapy to safely do heart sparing left breast cancer RT.

We are equipped with several techniques to protect heart and Lungs while treating breast cancer patients with radiation therapy some of which are mentioned below.

DIBH is an excellent technique technique for protecting heart and lung while doing radiation therapy for left breast cancer.

Prone Position:

At times patients are treated in prone position such that breast falls away from chest wall and hence increases distance from the heart to chest wall/breast. (Figure 3) This also helps considerably in decreasing doses to heart.

Partial Breast Irradiation (PBI):

In case of early breast cancers with favourable molecular profile, sometimes instead of treating whole breast, only small area around the breast tumour is treated with radiation therapy. This is called as partial breast radiation which also significantly reduces dose to heart.

Message :

With the present precise and advanced technologies, radiation therapy has become safer for breast cancer by protecting underlying heart and lungs.

10 Feb
Challenging Cases

Breast Cancer Radiation Therapy

Radiation Therapy (RT) for breast cancer has seen a long journey precision and focused therapy. RT is an important part of breast cancer management which improve both local control of cancer as well as patients survival.

In earlier times it was a treatment delivered over span of 5-7 weeks with unavoidable high doses of radiation going to underlying heart and lung. Now in the era of precision/ focused radiation therapy technique like IGRT and IMRT, in majority patient’s radiation is delivered over 3-4 weeks with much more safety for heart and lung.

In recent years precision of radiation therapy has further improved with several techniques to protect heart and lung with the most important being DIBH (Deep Inspiratory Breath Hold). In DIBH radiation is delivered in 4D fashion with respiratory gating to keep heart away while delivering radiation therapy.

Further improvement is that in selected patients whole radiation therapy treatment can be delivered over just 4-5 days (rather than weeks) using a technique called APBI (Accelerated Partial Breast Irradiation).

Breast Cancer APBI using intraoperative brachytherapy

Overall breast cancer radiation therapy has become a much shorter treatment with better safety and precision.

Dr Vineeta Goel is currently Director and Head Radiation Oncology at Cancer Institute, Shalimar Bagh. At Fortis Hospital Shalimar Bagh we routinely practice all these advanced techniques for treatment of cancers.

#BreastCancer #RadiationTherapy #APBI #BreastCancerRadiationTherapy

10 Feb
Challenging Cases

Stereotactic Radiotherapy

Conventional radiation therapy for cancers often results in some collateral damage to nearby healthy tissues. Stereotactic Radiotherapy (SRT) is defined as a method of external beam radiotherapy that use principles of stereotaxy to accurately deliver high radiation dose to a tumour/ target in one or few treatment fractions (1 to 5) without much radiation dose and side effects to the surrounding healthy tissues.

When this technique is used to treat brain tumours (primary /secondary) then it’s called as Stereotactic radiosurgery/ radiotherapy (SRS/SRT). While when this same technique is used for treating tumours outside brain/extra cranial , it’s called as SBRT (Stereotactic Body Radiation Therapy).

SRT is used to treat both primary cancers (where the cancer started such as the lung or the prostate), or where a cancer may have spread to other body organs (secondary cancers or metastases). It  is also addressed as SABR (Stereotactic ablative radiation therapy), as it involves the delivery of much higher and near ablative doses of radiation to cancer.

How is SRT different from other forms of RT?

• SBRT involves  high precision, image guided focused dose deliveredto the target with rapid dose fall off– translates in to higher control rates

• SBRT has highly conformal radiation with rapid dose fall off to avoid/minimize  radiation to healthy normal tissues – minimal side effects

• Larger doses per fraction (typically ≥ 8 Gy per fraction) to ablate the tumor- helps in overcoming radioresistance if any

• Fewer treatment fractions (typically 1-5 fractions) as compared to typical of 15-35 fractions in conventional RT

• Intra-fraction motion management wherever applicable for hitting at the accurate target every day with RT

What are the indications of using Stereotactic Radiation Therapy?

SRT can be used at various sites including

  • Primary Brain Tumours like Meningioma, Schwannomas etc.
  • Secondary Brain Tumour – Brain Metastases
  • Medically inoperable early-stage primary lung cancers (T1/2N0MO)
  • Lung metastasis (up to 5-8 in number)
  • Spine metastasis
  • Primary (Hepatocellular Carcinoma) and secondary liver tumours
  • Inoperable/recurrent  carcinoma pancreas
  • Early low risk prostate cancer

Case1 Carcinoma Cervix Patient with isolated liver metasatses treated with SBRT to liver metastases while sparing rest uninvolved liver

Case 2 –Follow up case of  Renal Cell Carcinoma with solitary brain metastases treated with post op SRT to Brain (without whole brain RT)

Case 3 – Carcinoma Urinary Bladder patient with Oligo metastases to Lung treated with SBRT with sparing of normal unaffected lungs

Case 4 Carcinoma Prostate with Spine metastases treated with SBRT to spine

Stereotactic RT delivers high ablative doses precisely to tumour which results in better tumour control and quick symptomatic relief to patients.

Dr. Vineeta Goel, Director Radiation Oncology at Fortis Hospital Shalimar Bagh is the best doctor for  STEREOTACTIC RADIOTHERAPY.

# Stereotactic radiation therapy #SRS #SRT #SBRT # Brain Metastases # Liver tumour # Liver Metastases # Spine metastases # Bone Metastases # Lung metastses

10 Feb
Challenging Cases

Stage IV Breast Cancer With Paralysis Of Lower Limbs

A 48 years old woman presented to us with paralysis of 4 days duration. She also gave a history of upper backache since past 5 months. She had a past history of being treated for right breast cancer with surgery, chemotherapy and hormonal therapy 7 years back. Clinically both her breasts and lymph node regions were normal. Neurologically her power in both lower limbs was reduced to 1/5 and rest everything was normal. We did a MRI spine for her which showed D4 Vertebral metastases with collapse and cord compression. She also underwent whole body PET CT scan which showed that she had multiple bone metastases and her rest body organs were free of cancer.

Patient was jointly evaluated by team of neurosurgeons, radiation and medical oncologists. She was taken up for neurosurgical tumour decompression and spine stabilization in view of recent onset paralysis and metastases being confined only to bones (which carries better prognosis as compared to patient having metastases in lungs or liver). After surgical decompression, her power in lower limbs improved to 2/5.

Surgery also yielded histopathology and biopsy which confirmed it to be metastases from breast cancer with strong hormonal positivity for Estrogen and Progesterone receptors.

Post- surgery she was started on hormonal tablets for breast cancer. Since her breast cancer was confined only to bones and it had strong positivity for hormonal receptors, she did not require any chemotherapy. She was planned for Stereotactic Body Radiation Therapy (SBRT) to affected D4 vertebrae. Her Radiation Therapy was planned using combined information from CT Myelogram and MRI Spine to spare spinal cord and focus high radiation doses only on cancer affected region. This radiation therapy was given over 5 days. She also underwent regular physiotherapy. As a result of this well planned intensive treatment and rehabilitation, she was up on her feet again.

This case exemplifies importance of multi disciplinary treatment, tumour board, newer radiation techniques like SBRT and quality of life of patients.

Dr Vineeta Goel, Associate Director Radiation Oncology at Max Super Speciality Hospital is the best doctor for  SBRT SPINE AND VERTEBRAL METASTASES.

10 Feb
Challenging Cases

Total Skin Electron Beam Therapy

Total Skin Electron Beam Therapy (TSET) is a radiation technique which is used to treat patient’s entire/total skin surface using electron beams .

TSET is used to treat Cutaneous T-Cell Lymphoma and/or Mycosis Fungoides. Mycosis Fungoides (MF) is a malignancy of helper T cells and accounts for 50% of all cutaneous lymphomas. Clinically it can present as erythematous and scaling skin patches which are generally annular or arc shaped. These later on progress to form infiltrative scaling plaques, nodules and sometimes have superficial ulcerations.

Aim while treating such type of cutaneous lymphomas is to deliver a therapeutic prescribed dose to entire skin of the body to a shallow depth by sparing the deep seated tissues and organs.

Technically TSET is a complex treatment and requires experienced team of Radiation Oncologists, Medical Physicists and Technologists to carry it out well. TSET requires complex dosimetry and quality assurance processes before and during treatment.

Everyday Patients nail bed and eyes are shielded before treatment using special applicators and lead goggles. (Fig 4)

At Max Hospital, Shalimar Bagh we have been treating patients of mycosis fungoides/cutaneous lymphomas with TSET regularly and with very rewarding results.

For each treatment, patients are  asked to stand in  different positions, alternating daily (total 6 positions) in front of Linear Accerlator. Each position exposes entire  patient’s skin to the radiation beam of  low energy electrons. (Figure 2-3)

Figure 2 – Patient positioned in front of Linear Accelerator

Figure 3- Clinical sketch of six treatment positions used for delivering TSET

 POSSIBLE SIDE EFFECTS OF TSET AND PREVENTIVE MEASURES:

  • Itchy skin –  keep skin moisturized, wear cotton cloths
  • Dry cracking skin – apply moisturizer
  • Sun sensitivity- wear sunglass , cap and full gown
  • Fatigue – take rest and eat healthy food
  • Temperature  regulation- Avoid humid hot weather and drink plenty of water
  • Partial temporary hair loss

Treatment Outcomes

TSET is the most effective treatment modality for MF.  It is a technically challenging and   demanding treatment modality and requires stringent quality assurance and team work.

10 Feb
Challenging Cases

Solitary Brain Metastases From Breast Cancer-Treatment With Stereotactic Radiation Therapy

A 54 Years old lady was diagnosed with left breast cancer in August 2015. Her breast biopsy confirmed it to be Invasive Ductal Carcinoma (IDC) with strong positivity for hormonal receptors (Estrogen and Progesterone) and negativity for Her 2 Neu (Epidermal Growth Factor Receptor). She underwent Left Breast Conservation surgery followed by chemotherapy and Radiation Therapy. After completion of radiation therapy, she was started on oral hormonal therapy treatment – in form of daily tablets.

She remained disease free for 34 months (2 years 10 months), when in October 2018, she had an episode of seizure. Clinically she was well preserved with ECOG performance status of 1, breast cancer was clinically controlled and she was neurologically intact. Contrast MRI Brain showed 1.5×1.4 x1.6 cm intensely enhancing nodule in left posterior frontal region with mild surrounding edema suggestive of solitary brain metastases. MR Spectroscopy showed intense choline peak with reduced NAA suggestive of mitotic etiology. Patient also underwent FDG whole body PET CT scan which showed that brain was the only site of metastases.

Diagnosis

Her final diagnosis was Solitary Brain Metastases from Left Breast Cancer after disease free interval of 34 months in a 54 years old well preserved lady.

Management

Patient was evaluated for surgical resection with the idea that it would also give histo biopsy specimen to repeat hormonal and other IHC markers profile to decide systemic treatment. Her functional MRI brain showed motor activation area in close proximity to metastases and Broca’s area close to FLAIR abnormality. Neurosurgical resection of brain lesion was ruled out in view of location in close vicinity of motor and speech area.

She was then treated with stereotactic brain radiation therapy. He head was fixed in a non- invasive frame/mould. Since her lesion was lying in eloquent area (close to motor and speech cortex), her radiation therapy (RT) was delivered in 3 fractions instead of single fraction RT. She was treated with 27Gy in 3 fractions to brain metastases using stereotactic radiosurgery (SRS) technique under image guidance.

After brain radiosurgery her hormonal treatment was changed in form of another pill. She was not given chemotherapy as her previous breast cancer was hormone receptor positive.

Follow up

Post brain SRS, patient has a follow up of one year 3 months (15 months) and she is disease free. She has no neurological deficit and she continues to be on hormonal treatment. Her repeat MRI Brain showed small residual non enhancing lesion of 6×7 mm and there are no new cranial or extracranial lesions.

Discussion

In past decade, there has been a major shift in approach to management of metastatic cancers with an attempt to potentially cure especially oligo (few/limited) and solitary metastases. This potentially curative treatment approach requires systemic treatment along with aggressive local treatment of metastases either with surgery or ablative high dose radiation therapy with stereotactic approaches (SRS or SBRT).

Till few years back standard treatment of brain metastases was whole brain radiation therapy (WBRT). A new standard of care for brain metastases is to give focal stereotactic radiation therapy. There are several advantages of SRS over WBRT including short treatment, better local control of metastases, no neurocognition decline and no hair loss.

10 Feb
Challenging Cases

Intra Operative Radiation Therapy (IORT) With Brachytherapy

Intraoperative radiation therapy (IORT) is single dose of focused radiation therapy delivered at the time of surgery.

Brachytherapy is an internal form of radiation therapy and is considered the most conformal (focused/precise) technique.

Brachytherapy when use intraoperatively becomes further focused and spot on.

In cancer treatment, there are several indications of using IORT, with the commonest being

  1. Recurrent lymph node within the region previously treated with radiation therapy. These lymph nodes can be in neck, axilla (arm pit) or abdomen.
  2. Recurrent cancer in primary (or site of origin of cancer) where either previously radiation has been done or in sites where it’s difficult to get surgical margins clear at microscopic level (at the level of cells). Common cancers where it is used are rectal cancer, mouth cancers and some pediatric cancers.

Procedure
Pre-operatively patient is jointly evaluated by Surgical and Radiation Oncologist in OPD to take decision regarding need for IORT.
Surgery is done in a special OT with brachytherapy machine in Operation theatre. After surgical removal of tumour, IORT applicator is placed and secured (stitched) to tumour bed (region from where tumour is removed). A quick IORT brachytherapy plan is generated depending on size of applicator and radiation dose to be delivered (generally takes 10 minutes). After planning IORT applicator is connected to brachytherapy machine and radiation therapy is delivered usually over 20-30 minutes. Brachytherapy applicator is then removed and surgical oncologist completes surgery.

Advantages
IORT with Brachytherapy is the most focused and precise form of radiation therapy as its penetration is only about a centimeter deep to where applicator is placed.
It gives high dose to tumour bed with minimum dose to surrounding normal organs.

10 Feb
Challenging Cases

Management Of Intracranial Non Germinomatous Germ Cell Tumour (Choriocarcinoma) Brain With Chemotherapy And Cranio Spinal Radiation Therapy

18 Years old college student presented to hospital with complaints of severe headache, blurring of vision, vomiting and episode of unconsciousness. Clinically patient was conscious, alert but very irritable with normal sensory motor function. He underwent initially CT Head followed by contrast MRI Brain which showed 30x 41 x 39 mm heterogeneous lesion in posterior aspect of third ventricle with contiguous parenchymal infiltration with radiological diagnosis of pineal germ cell tumour.

Subsequently his serum ß HCG was found to be 1, 11, 505 mIU and AFP of 1.36 ng/ml. He underwent CSF sampling which showed no malignant cells on cytology with CSF ß HCG of 1, 40, 614 mIU/ml and AFP of <0.5 ng/ml. His MRI Spine screening was also normal.

Diagnosis

Based on his radiological picture coupled with raised serum and CSF ß HCG with normal AFP, diagnosis of Primary CNS non seminomatous germ cell tumour (NSGCT) with subtype Choriocarcinoma was made.

Management

Patient initially underwent VP shunt control symptoms of raised intracranial pressure and was then started on chemotherapy. After completing four cycles of chemotherapy his serum and CSF ß HCG decreased significantly to 8.4 and 68.6 mIU/ml respectively. His repeat MRI Brain showed much smaller residual disease. Patient also showed much improvement symptomatically.

He was then treated with Cranio Spinal Irradiation (CSI) with Intensity Modulated Image Guided Radiation Therapy (IM IGRT) to a dose of 30.6Gy in 17 fractions followed by local tumour boost to 19.8Gy over 11 fractions. This whole treatment was carried out on TruBeam STX Linear Accelerator at Max Hospital, Shalimar Bagh. Patient tolerated CSI radiation therapy well with grade II haematological and grade I GI toxicity. Patient completed his entire treatment in July 2018.

Follow up

Patient has been on regular follow up for last 18 months and his diseases remains in remission clinically, radiologically and biochemically and he has resumed back his studies in college.

Discussion

Primary Choriocarcinoma of brain is a rare tumour. Biopsy is generally not mandatory for its confirmation as diagnosis is generally made by combination of radiological picture along with raised serum and CSF ß HCG. Surgical resection of tumour is also generally not required as this tumour is very chemo and radio sensitive. Response to treatment is generally done by repeating serum and SCF ßHCG values which should show declining values.

Radiation therapy target for NSGCT Brain includes entire brain and spinal axis including leptomenninges and is termed as cranio spinal radiation. It’s a large and irregular target volume spanning almost across patient’s whole body. Covering cranio spinal axis with radiation therapy also comes with challenge of sparing all organs of body (lung, heart, kidney, esophagus) and cranial structures like eyes, lens, cochlea etc.

With present radiation therapy techniques, it is possible to treat this irregular target volume of brain and spine using combined technique of intensity modulated image guided radiation therapy (IM- IGRT). IMRT helps us to focus radiation doses at correct region while saving adjacent normal organs. IGRT involves using on board Cone beam CT Scan to verify patient positioning every day before radiation therapy.

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