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    PowerPoint Slides English Brazilian Portuguese Translation

    Breast Cancer: Radiotherapy Treatment Approaches Video Transcript

    Cncer de mama: abordagens do tratamento radioterpico Transcrio de vdeo

    Professional Oncology Education Breast Cancer: Radiotherapy Treatment Approaches Time:43:04

    Educao Profissional em Oncologia Cncer de mama: abordagens do tratamento radioterpico Durao:43:04

    Wendy Woodward, M.D., Ph.D. Associate Professor Radiation Oncology The University of Texas MD Anderson Cancer Center

    Dra. Wendy Woodward, M.D., Ph.D. Professora associada Radiologia Oncolgica MD Anderson Cancer Center Universidade do Texas

    Hello. My name is Wendy Woodward. Im an Associate Professor on the Breast Section in the Department of Radiation Oncology at The University of Texas MD Anderson Cancer Center. Today Im going to talk about Radiation Therapy Approaches for Breast Cancer.

    Ol. Eu sou Wendy Woodward. Sou professora da Diviso de Mama do Departamento de Radiologia Oncolgica do MD Anderson Cancer Center da Universidade do Texas. Hoje falarei sobre as abordagens da radioterapia no cncer de mama.

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    At the conclusion of this discussion, we anticipate that you would be able to highlight the role of radiation in breast cancer; specifically regarding patient selection as well as dose and technical issues; and discuss current topics in fractionation, volume, and technology.

    Na concluso desta discusso, prevemos que vocs possam destacar o papel da irradiao no cncer de mama, especificamente no que concerne seleo de pacientes e assuntos tcnicos e relacionados dose, e discutir temas atuais sobre fracionamento, volume e tecnologia.

    Across cancer subsites, the first principles of radiation are the same. Greater volume of disease requires greater dose for control. In prostate cancer, where commonly the disease is in place at the time of radiation, higher dose is needed than after a mastectomy or lumpectomy in radiation where you anticipate the only potential rem --- remaining disease is microscopic. Target the disease while sparing the normal tissue. This is obvious but critical. Dont give more or less dose than required. Ideally, you would give 100% of your prescription dose to all off the desired tissue and no dose to any other tissue. And well discuss approaches to try and optimize this goal. And, lastly, dont miss.

    Em vrios subcentros de cncer, os primeiros princpios de irradiao so iguais. Doenas com maiores volumes exigem doses maiores para seu controle. No cncer de prstata, em que geralmente a doena est presente no momento da radiao, precisa-se de uma dose maior do que aquela aps uma mastectomia ou nodulectomia, nas quais o esperado que o remanescente da doena seja microscpico. Atingir a doena preservando o tecido normal. Isto bvio, mas fundamental. No administrar nem mais nem menos dose do que a necessria. Idealmente, administraramos 100% da dose prescrita a todo o tecido em questo e nenhuma dose aos demais tecidos. Discutiremos abordagens para tentar e otimizar esta meta. E por fim, no errem [o alvo].

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    Radiation therapy has evolved over the --- the last few decades as you would expect. From the time that radiation therapy was first introduced into a clinical setting, treatment setup was fairly primitive. A linear accelerator, a Van de Graaff accelerator, a cobalt unit would be installed. And the patient would largely be positioned in front of it, occasionally without immobilization devices. And you had relatively limited control over the aperture that allowed radiation therapy to come from the generator to the patient. In the seventies, a major step forward was whats called an asymmetric jaw, where now, asymmetric jaw is located in the head of the machine, allows you to generate an aperture which was not perfectly square. You could then put blocks into this to try and shape the field in the shape of the target you were trying to treat. This moved forward again with the addition of Cerrobend blocks, demonstrated here, where you could now actually generate irregular contours to target your tumor, and finally, more recently has moved forward into the development of whats called a multileaf collimator. Also located in the head of the machine, the computer can drive individual leaves across the aperture opening to shape the opening or for radiation to emerge into the shape of the desired target. This can further be controlled by the computer to actually move dynamically as radiation is delivered, to change the intensity, modulate the intensity of the radiation therapy, a technique known at IMRT. Weve come a long way.

    A radioterapia vem se desenvolvendo nas ltimas dcadas como era de se esperar. Desde a introduo da radioterapia no ambiente clnico, o arranjo teraputico era bastante primitivo. Seria instalado um acelerador linear, um acelerador Van de Graaff, uma unidade de cobalto. Em grande parte, o paciente seria posicionado frente do aparelho, de vez em quando sem dispositivos de imobilizao. E o controle que dispnhamos sobre a abertura que permitia a irradiao passar do gerador ao paciente era relativamente limitado. Nos anos setenta, um importante passo frente foi o que se chamou maxilar assimtrico, o que, agora, localizado na cabea da mquina e possibilita gerar uma abertura que no era perfeitamente quadrada. Nele podiam ser colocados blocos para testar e dar forma ao campo que coincidisse com a forma do alvo que se queria atingir. Um novo avano alcanado foi com a adio de blocos de Cerrobend, demonstrado aqui, com o que podamos realmente gerar contornos irregulares para atingir o tumor e, finalmente, mais recentemente, o avano no desenvolvimento do denominado colimador multilminas. Tambm localizado na cabea da mquina, o computador pode direcionar lminas individuais atravs da abertura para conform-la ou para a radiao emergir na forma do alvo desejado. Isso pode ser ainda mais controlado pelo computador para mover dinamicamente enquanto a irradiao est sendo emitida, para mudar a intensidade, modular a intensidade da terapia de irradiao, uma tcnica denominada IMRT. Progredimos muito.

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    In 2D planning, before the integration of CT scanning into radiation treatment planning, patients arrived for radiation therapy planning at what was called a simulation. This was usually done on a fluoroscopic simulator, and x-rays and bony anatomy were used to determine the target. And the apertures in the radiation accelerator were set. And blocks were drawn on x-ray images. Subsequently, a single plane contour of the anatomy was designed and at the mid plane of the field, the dose would be estimated or calculated by hand, generating a relatively rudimentary but accurate description of the dose across the tissue in that plane.

    No planejamento 2D, antes da integrao da TC com o planejamento do tratamento radioterpico, os pacientes chegavam para o planejamento da radioterapia no que nesse ento era chamado simulao. Normalmente, isso era feito em um simulador com fluoroscopia e, para determinar o alvo, eram utilizadas radiografias e estruturas sseas. As aberturas no acelerador de irradiao eram fixadas e os blocos eram desenhados nas imagens de radiografia. Subsequentemente, um nico contorno plano da estrutura anatmica era projetado e no plano central do campo, a dose seria estimada ou calculada mo, gerando uma descrio relativamente rudimentar, mas precisa da dose atravs do tecido nesse plano.

    The integration of CT scanning in the nineties, however, developed a much more accurate means of modeling the dose throughout the entire tissue targeted, and as a result, the ability to homogenize the dose, to generate that ideal 100% isodose line for your prescription was improved dramatically. Also the ability to limit dose in normal tissues that are not intended to be irradiated was improved dramatically. You can use the planning system now to model dose clouds that are excess dose. That are [a] consequence of physics that are not intended. You can block these out with a technique called field-in-field, and ultimately visualize the modeling of the dose throughout the breast to determine whether youve generated a relatively homogenous 100% dose plan with minimal hot spots. This is desirable to minimize the toxicity to the skin and other normal tissues.

    Nos anos 90, contudo, com a integrao da varredura da TC, desenvolveram-se meios muito mais precisos de modelagem da dose por todo o tecido alvo e, como resultado, a capacidade de homogeneizar a dose, de gerar aquela linha de isodose ideal de 100% da prescrio, melhorou drasticamente. Tambm a capacidade de limitar a dose em tecidos normais, os quais no se pretendiam irradiar, teve uma melhora radical. Agora, podemos usar o sistema de planejamento para modelar nuvens de doses que esto em excesso. Isso [uma] consequncia da fsica que no tinha sido prevista. Podemos bloque-los com uma tcnica chamada field in field e, basicamente, visualizar a modelagem da dose atravs da mama para determinar se foi gerado um planejamento dosimtrico relativamente homogneo de 100% com um mnimo de reas irradiadas. Isto desejvel para minimizar a toxicidade da pele e outros tecidos normais.

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    The benefit of radiation therapy has been clearly demonstrated again and again in numerous randomized trials. The Early Breast Cancer Trialists Collaborative Group is a group which takes the individual data from randomized trials which have been co --- conducted and pools them together to try and look broadly at the benefit of different cancer therapies including radiation therapy. Here you can see the primary outcome of this analysis for radiation therapy, which is that the benefit is relative to the risk. Here, in comparisons where the risk of local recurrence, thats a re