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Evolução da Tecnologia - Radioterapia - Mama

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Ricardo Op

on 23 March 2017

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Transcript of Evolução da Tecnologia - Radioterapia - Mama

Evolucão da Radioterapia
DIAGNOSTICO
TRATAMENTO
ESTADIAMENTO
SERVIÇO DE RADIOTERAPIA
ACISO - IRUPI 2014
Evolução da Radioterapia
As vantagens da tecnología para o Diagnóstico, Estadiamento e Tratamento de Cáncer com Radioterapia.
Obrigado
Future
Present
Past
Ultrasound
MRI
Digital Mammography
Early Mammography
4D-CRT
Makes use of infra-red tracking of markers
Combines with deep inspiration breath hold (DIBH)
Respiration movement can vary from 0.5 to 0.7cm
Demonstrated to reduce lung and cardiac doses

Digital Breast Tomosynthesis (DBT)
Positron Emission
Mammography
IMRT
Inverse planning
Greater dose distributions leads to reduced side effects
Increased planning and treatment times
Increase MU/integral dose to healthy tissue


VMAT
Rotational therapy
Produces similar or better results as IMRT, but with reduced treatment times
A single arc for a large target volume may be less sensitive to unexpected organ motion during dose delivery
Longer planning times and availability of machines


http://radonc.ucla.edu/body.cfm?id=242
2D CRT
Uses single, central slice CT scan
Manual dosimetry
Unwanted radiation dose inhomogeneity in the breast produces late adverse effects
Incidence of change in breast appearance was statistically significantly higher in patients in the standard 2D treatment


(a) 2D plan and (b) IMRT plan. Colour scale: dark blue = 90%, mid blue = 95%, light blue = 98%, mid green = 100%, light green = 102%, yellow = 105%, orange = 110%, red = 112%. (Donovan et al., 2007)
Now
Lymphoscintigraphy
Sentinel Lymph Node Biopsy (SLNB)
Nuclear Medicine Bone Scan
Positron Emission Tomography (PET)
Computed Tomography (CT)
Then
Axillary Lymph Node Dissection (ALND)
Between 5-30 nodes removed
Nodes tested for metastatic spread
Associated with lymphedema, impaired
arm mobility and scarring
Now
PET/CT
Radioactive colloid injected interstitially or intradermal
Lymphatic pathway mapped to
locate sentinal node
Lowers morbidity and improves cosmetic outcomes
99.1% accuracy when used in conjunction with blue
dye

(Kowalsky & Falen, 2011)

Lymphoscintigraphy
&
SLNB
Left: Digital Mammography
(Park, Franken et al. 2007)
(Bassett & Gold, 1988)
Breast imaging introduced 1920's:


Specific Mammography units developed 1960's:


Introduced late 1980's


Useful for Imaging:




Unable to detect
micro-calcification
High risk patients
Large, dense breasts
Implants
Introduced 2000's:


Advantages of Digital Technology:




Low spatial resolution compared to screen-film
Digital magnification
Contrast manipulation
Digital storage (PACS)
Rapid image transfer
Recent extension of digital mammography

Advantages


Same dose as digital
mammography

Current clinical trials:
Reduces structural overlap
Increases detection sensitivity and specificity
Oslo Trial - evaluating effectiveness of DBT
Malmo Trial - comparing DBT to digital mammography
99mTc HDP/MDP injected
Accumulates within bone in areas of increased osteoblastic activity
Specifically looking for bony metastases

(Kowalsky & Falen, 2011)
Figure: (Park, Franken et al. 2007)
Nuclear Medicine Bone Scan
PET & CT can be used simultaneously or as separate scans
In PET, FDG tracer injected
Tracer concentration is highest in areas of high metabolic activity
CT of thorax demonstrates any local/regional spread

(Sone, et al., 2001)
INTRA-OPERATIVE RT
Utilized during breast conserving surgery
A single fraction dose of 20 Gy to tumour bed
Reduces time, cost, over treatment and lowers the rate of local recurrence
Considered experimental
, more trials required to justify as a sole treatment option

Perguntas?
3D CRT
Uses multiple CT slices and computer calculations
Breast dosimetry can be significantly improved and has little impact on radiotherapy resources
Leads to better tumour control probability and cosmetic results
Less skin and lung side effects in patients with conserved breast


Past
Present
Future
Lower dose & improved image
quality over time
1960's
high exposures & low sensitivity
1970's
1980's
(Van Steen & Van Tiggelen, 2007)
Increased contrast & reduced dose
(Van Steen & Van Tiggelen, 2007)
Introduced late 1990's


Advantages of
Ultrasound:

Useful in image guided biopsies
Differentiating cysts, and solid masses
Highly sensitive in younger women
A: Whole breast mediolateral mammographic image
B: Targeted ultrasound image
(Cochrane Miller, 2006)
(Lowry, 2012)
(Donovan et al., 2007)
Right: Digital Tomosynthesis
(Barnett et al., 2009; Falahatpour, Aghamiri & Anbiaee, 2011; Moser & Vrieling, 2012)
(Haertl et al., 2013; McCormick & Hunt, 2011)
(Haertl et al., 2013; Popescu et al., 2010)
(Borst et al., 2010; Kinoshita et al., 2008; Vikstorm, Hjelstuen, Mjaaland & Dybvik, 2011)
(Barry & Sacchini, 2012; Moser & Brieling, 2012)
(Kilburn-Toppin and Barter, 2013; Linder and Schiska, 2008)
(Kilburn-Toppin and Barter, 2013; Linder and Schiska, 2008)
(Brice, 2010)
Digital screening mammogram (left) and screening PEM (right)
Detect uptake of radiopharmaceutical in breast lesions

Shows functional information
Image A: MRI with abnormal contrast enhancement Image B: mammogram
Ricardo Ochoa Pachas, MSc.
Caso de exemplo:
Cáncer de Mama
Evolução da Radioterapia
Ricardo Ochoa Pachas
Físico Médico
Full transcript