• Users Online: 1613
  • Print this page
  • Email this page


 
 
Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 136-139

Cancer of right breast with single-liver metastasis-simultaneous treatment of chest wall with radiotherapy for carcinoma breast and SBRT for liver lesion: Procedural details of the complex procedure


1 Department of Radiation Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, Andhra Pradesh, India
2 Department of Medical Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, Andra Pradesh, India
3 Department of Radiation Oncology, Acharya Harihar Regional Cancer Centre, SCB Medical College, Cuttack, Odisha, India
4 Department of Medical Physics, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, Andhra Pradesh, India

Date of Submission20-Sep-2021
Date of Acceptance19-Oct-2021
Date of Web Publication23-Feb-2022

Correspondence Address:
Dr. Kanhu Charan Patro
Department of Radiation Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, Andhra Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jco.jco_33_21

Rights and Permissions
  Abstract 

Breast cancer with oligometastasis is not uncommon. Greater therapeutic advantage has been reported in various literatures with evolution of treatment technique. Here we report a case of ductal carcinoma right breast with a single metastasis to liver. This patient was treated with radical intent with chemotherapy, surgery, and then followed by radiotherapy to right chest wall along with stereotactic body radiotherapy for liver metastasis. Each treatment per se is not complicated. When radiation delivered to both chest wall and liver, the cumulative dose to liver is the main concern. Here we present the procedural details of this complex procedure.

Keywords: Oligometastasis, radiotherapy technique, SBRT


How to cite this article:
Patro KC, Damodara VN, Boyya RR, Kundu C, Bhattacharyya PS, Pilaka VK, Padhi S, Muvvala M, Reddy P S, Avidi VS, Atchaiyalingam M, Karthikeyan K, Prabu AC, Srinu A, Prasad P, Kumar AA. Cancer of right breast with single-liver metastasis-simultaneous treatment of chest wall with radiotherapy for carcinoma breast and SBRT for liver lesion: Procedural details of the complex procedure. J Curr Oncol 2021;4:136-9

How to cite this URL:
Patro KC, Damodara VN, Boyya RR, Kundu C, Bhattacharyya PS, Pilaka VK, Padhi S, Muvvala M, Reddy P S, Avidi VS, Atchaiyalingam M, Karthikeyan K, Prabu AC, Srinu A, Prasad P, Kumar AA. Cancer of right breast with single-liver metastasis-simultaneous treatment of chest wall with radiotherapy for carcinoma breast and SBRT for liver lesion: Procedural details of the complex procedure. J Curr Oncol [serial online] 2021 [cited 2022 May 17];4:136-9. Available from: https://www.journalofcurrentoncology.org/text.asp?2021/4/2/136/338058




  Introduction Top


Breast cancer is the second most prevalent cancer worldwide and the is overall the most common cancer in Indian females. Oligometastatic breast cancer refers to a subset of patients with metastatic breast cancer with limited disease often about less than 5 deposits. The incidence of oligometastatic breast cancer is ~20 – 50%. SBRT proves to be a valuable tool in achieving local control in such oligometastatic sites. Here, we describe one such case scenario of hormone receptor positive right sided breast cancer with a solitary liver metastasis treated with curative intent by neo adjuvant hormonal therapy, surgery and adjuvant radiotherapy to the primary site and stereotactic body radiotherapy to the metastatic liver lesion.


  Case Report Top


A 56-year-old woman presented with a lump that was situated in the upper and outer quadrant of the right breast. It was not tender, firm, and mobile. The patient was investigated in the line of breast cancer for further management. Histopathology and receptor studies of this patient revealed it to be infiltrative duct carcinoma, estrogen receptor positive, progesterone receptor positive, and human epidermal growth factor (HER2) negative. Her metastatic workup revealed a single 2 cm × 2 cm lesion in segment VI of liver suggestive of distant metastasis. Positron emission tomography-computed tomography (PET-CT) scan showed local breast lesion (3.3 cm × 2.6 cm size with standardized uptake value (SUV) max 8.4), right axillary node (2 cm size with SUV max 1.4), and liver lesion in liver segment VI (17 mm × 16 mm with SUV 9.3). After discussion in the multidisciplinary tumor board, it was decided to treat the patient with radical intent with neoadjuvant hormonal therapy followed by modified radical mastectomy and chest wall radiation and stereotactic body radiotherapy (SBRT) for liver lesion. The patient was also planned to receive tab Palbociclib (125 mg) per oral daily for 3 weeks on and 1 week off, for three cycles along with Letrozole (2.5 mg) once daily. After completion of neoadjuvant chemotherapy, there was a good clinical response in breast lesion with stable liver lesion. Then patient underwent surgery, modified radical mastectomy, and axillary dissection. Histopathology was ypT2N1AM0. She was then subjected to external radiation to right chest wall by Deep Inspiratory Breath Hold (DIBH) technique and SBRT for liver lesion [Figure 1].
Figure 1: (A and B) Simulation with deep inspiratory breath hold

Click here to view



  Radiotherapy Procedural Details Top


It is a right-sided breast cancer and during chest wall irradiation some part of liver also gets irradiated. Also, simultaneously the patient is planned for stereotactic radiotherapy for liver lesion. It seems to be a complicated procedure as part of the liver comes into the radiation field twice, during external beam radiation therapy (EBRT) to chest wall and during SBRT[1] to liver lesion. Keeping these in mind, the patient is planned both for chest wall radiotherapy by tangential field with DIBH technique and for SBRT to liver lesion with same DIBH using ABC (active breath control). First, the triple-phase CT of liver lesion is analyzed. It is found that the lesion is more prominent and enhancing in arterial phase [Figure 2]. Planning CT scan was taken for liver, with DIBH technique, using ABC. The timing of breath-hold is made such that it will coincide with starting of the arterial phase. Then planning CT for the right chest wall with DIBH using ABC software is taken with CT slices from the mandible to umbilicus.
Figure 2: Imaging

Click here to view


The target volumes are contoured as per ESTRO contouring guidelines [Figure 3][2] and the patient receives the radiation to right chest wall and supraclavicular fossa to a total dose of 40.05 GY in 15 fractions as per START B protocol.[3] It is tried to keep the liver dose to as minimum as possible and the mean liver dose in chest wall plan with DIBH is calculated. In the second plan, that is, SBRT to liver lesion was planned for 15 Gy per fraction in three factions with a BED of more than 100 Gy. The mean liver dose to the liver-gross tumor volume (GTV) was calculated. The chest wall and SBRT liver planning CT were fused and calculated cumulative liver mean dose, which was 10 Gy and we kept the constraints as per TG101 PROTOCOL[5] and liver-GTV D700 cc was 3 Gy [Figure 4].
Figure 3: Target delineation

Click here to view
Figure 4: Fused plans showing dose distribution

Click here to view



  Discussion Top


Nowadays, for carcinoma breast having oligometastasis, the trend is to treat it with intention to cure. Statistics show that the incidence of localized breast cancer is 29%, locoregional is 57%, distant metastasis is 10.3%, and spread to unknown extent is 3.7% at the time of diagnosis (Indian Statistics Vide National Cancer Registry Program published by ASCO 2020).[4] There are no clear-cut guidelines for the procedural details about chemotherapy and radiotherapy sequencing. There are also no guidelines for treatment of local and metastatic disease with radiotherapy. Here we treated the patient with radical intent. We did not find any comparable literature about procedural details of cases like this. We explained here the procedures that are being followed here in detail. It is being suggested that, if there happens to be carcinoma breast with oligometastasis to liver can be treated with radical intent using DIBH technique, the detailed procedure laid down here. If you plan the breast/chest wall without DIBH, the liver may get more radiation doses, and if you do not fuse both the planning CTs you cannot calculate the cumulative dose to the liver which is very vital for such type treatment.

Steps to be followed

Step1: Plan with motion management system for such type of situation.

Step2: Take planning CT which includes both chest wall and abdomen with desired motion management system. For simulation, there will be two planning CTs in the same sitting without disturbing the patient, so that they can be fused perfectly for dosimetry

Step3: Plan the chest wall or for breast with tangential fields and block the liver as much as possible.

Step4: Plan SBRT for liver and avoid beam entry in the upper part of liver if possible.

Step5: Fuse both planning CT (CT thorax and CT abdomen) and calculate the combined mean dose to liver.

Step6: Execute the treatment as per plan with daily cone beam computed tomography (CBCT) and motion management [Figure 5].
Figure 5: (A-C) Image verification

Click here to view



  Conclusion Top


This type of treatment procedure and technique can be undertaken in primary breast cancer with oligometastasis to liver. It should be done with extreme caution, with meticulous attention to motion management for both primary breasts during chest wall irradiation as well as during SBRT for liver metastasis. Liver dose constraint has to be kept in consideration while planning for Liver SBRT.

With the availability of advanced treatment techniques, there is a paradigm shift of treatment intent of metastatic carcinoma breast. For oligometastasis, still the treatment intent can be radical with the availability of better chemotherapy and advance radiotherapy techniques.

It is now possible that when the distant metastasis is oligometastasis and there is availability of advance treatment technique metastatic breast cancer can be approached with radical intent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Haviland JS, Owen JR, Dewar JA, Agrawal RK, Barrett J, Barrett-Lee PJ, et al.; START Trialists’ Group. The UK Standardization of breast radiotherapy (START) trials of radiotherapy hypo fractionation for treatment of early breast cancer: 10 years follow up results of two randomized controlled trials. Lancet Oncol2013;14:1086-94.  Back to cited text no. 1
    
2.
Gee HE, Moses L, Stuart K, Nahar N, Tiver K, Wang T, et al. Contouring consensus guidelines in breast cancer radiotherapy: Comparison and systematic review of patterns of failure.J Med Imaging Radiat Oncol2019;63:102-15.  Back to cited text no. 2
    
3.
Mathur P, Sathishkumar K, Chaturvedi M, Das P, Sudarshan KL, Santhappan S, et al.; ICMR-NCDIR-NCR Investigator Group. Cancer statistics, 2020: Report From National Cancer Registry Programme, India. JCO Glob Oncol 2020;6:1063-75.  Back to cited text no. 3
    
4.
Offersen BV, Boersma LJ, Kirkove C, Hol S, Aznar MC, Biete Sola A, et al. ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage. Breast Radiother Oncol 2015;114:3-10.  Back to cited text no. 4
    
5.
Benedict SH, Yenice KM, Followill D, Galvin JM, Hinson W, Kavanagh B, et al. Stereotactic body radiation therapy: The report of AAPM Task Group: 4078-101. Erratum in: Med Phys2012;39:563.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Radiotherapy Pro...
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed150    
    Printed4    
    Emailed0    
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal