|Year : 2021 | Volume
| 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
Kanhu Charan Patro1, Venkata Naga Priyasha Damodara1, Rakesh Reddy Boyya2, Chitaranjan Kundu1, Partha Sarathi Bhattacharyya1, Venkata Krishna Reddy Pilaka1, Sanjukta Padhi3, Mrutyunjayarao Muvvala1, P Srinivasuslu Reddy1, Veera Surya Premchand Kumar Avidi1, Mohanapriya Atchaiyalingam1, Keerthiga Karthikeyan1, Arunachalam Chithambara Prabu4, Aketi Srinu4, Parasa Prasad4, Ayyalasomayajula Anil Kumar4
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 Submission||20-Sep-2021|
|Date of Acceptance||19-Oct-2021|
|Date of Web Publication||23-Feb-2022|
Dr. Kanhu Charan Patro
Department of Radiation Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
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|| |
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|| |
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].
| Radiotherapy Procedural Details|| |
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 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.
The target volumes are contoured as per ESTRO contouring guidelines [Figure 3] 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. 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 and liver-GTV D700 cc was 3 Gy [Figure 4].
| Discussion|| |
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). 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].
| Conclusion|| |
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]