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

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DOI:
10.4103/jco.jco_33_21
Address for correspondence:
Dr. Kanhu Charan Patro,
Department of Radiation Oncology, Mahatma Gandhi Cancer Hospital and
Research Institute, Visakhapatnam, Andhra Pradesh, India.
E-mail: drkcpatro@gmail.com
Received: 20 September 2021; Revised: 10 October 2021;
Accepted: 19 October 2021; Published: 23 February 2022
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How to cite this article: Patro KC, Boyya VN, Kundu C,
Bhattacharyya PS, Pilaka VK, Padhi S, et al. Cancer of right breast
with single-liver metastasis-simultaneous treatment of chest wall with
radiotherapyforcarcinomabreastandSBRTforliverlesion:Procedural
details of the complex procedure. J Curr Oncol 2021;4:136-9.
Case Report
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 Patro, Venkata Naga Rakesh Reddy Boyya1
, Chitaranjan Kundu, Partha Sarathi Bhattacharyya, Venkata Krishna Reddy Pilaka, Sanjukta Padhi2
,
Mrutyunjayarao Muvvala, P
. Srinivasuslu Reddy, Veera Surya Premchand Kumar Avidi, Mohanapriya Atchaiyalingam, Keerthiga Karthikeyan,
Arunachalam Chithambara Prabu3
, Aketi Srinu3
, Parasa Prasad3
, Ayyalasomayajula Anil Kumar3
Department of Radiation Oncology, 1
Department of Medical Oncology, Mahatma Gandhi Cancer Hospital and Research Institute, Visakhapatnam, 2
Department of
Radiation Oncology, Acharya Harihar Regional Cancer Center, SCB Medical College, Cuttack, Odisha,3
Department of Medical Physics, Mahatma Gandhi Cancer
Hospital and Research Institute,Visakhapatnam, Andhra Pradesh, India
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
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
rightsidedbreastcancerwithasolitarylivermetastasistreated
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
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2. Patro, et al.: Cancer of right breast with single-liver metastasis
Journal of Current Oncology ¦ Volume 4 ¦ Issue 2 ¦ July-December 2021 137
(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[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.
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].
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).[4]
There are no clear-cut guidelines for the
procedural details about chemotherapy and radiotherapy
Figure 1: (A and B) Simulation with deep inspiratory breath hold
Figure 2: Imaging
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3. Patro, et al.: Cancer of right breast with single-liver metastasis
138 138 Journal of Current Oncology ¦ Volume 4 ¦ Issue 2 ¦ July-December 2021
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 3: Target delineation
Figure 4: Fused plans showing dose distribution
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4. Patro, et al.: Cancer of right breast with single-liver metastasis
Journal of Current Oncology ¦ Volume 4 ¦ Issue 2 ¦ July-December 2021 139
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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Figure 5: (A-C) Image verification
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