PowerPoint Presentation

[Virtual Presenter] Good morning everyone. Today I'm going to discuss a major breakthrough in breast cancer treatment called TARGIT-IORT. Fardeen Bhimani MD, a Research Fellow in Breast Surgery and Valery Uhl MD, a Radiation Oncologist, both specialize in breast surgery and radiation oncology respectively, in Northern California, and together they focus on special situations for Breast TARGIT-IORT. With this technology, the traditional days of radiation being the only treatment are in the past. Let's learn more about why TARGIT-IORT is becoming the preferred treatment option..

[Audio] Two doctors in Northern California specialize in breast surgery and radiation oncology, with a focus on special situations for Breast TARGIT-IORT. To extend patient education about this procedure, www.targetbreastcancer.org was created. This website has been visited by people from all around the globe and provides stories from those who have received TARGIT-IORT. This serves as an excellent learning resource for both patients and healthcare professionals, and doctors can document that this information was provided in patient charts..

[Audio] TARGIT-IORT offers a unique option to address complex patient conditions in one treatment. It combines radiation oncology and breast surgery, giving patients the opportunity to protect their breast while still receiving the treatment they need. This is why many patients choose this approach. TARGIT-IORT has an especially high potential to preserve the patient’s breast, and enable them to get back to their lives after only one treatment..

[Audio] Drs. Fardeen Bhimani and Valery Uhl specialize in procedures that are tailored to the individual's needs when it comes to treating breast cancer. They offer TARGIT-IORT, a radiation therapy that can be used to treat early-stage breast cancer with minimal EBRT boost. This is a risk-adapted approach, meaning those with poorer prognoses receive WBI. Furthermore, if a tumor is present on ink, and depending on the stance taken about Z-11, positive margins may require WBI aswell. Dr. Uhl's team began cautiously with IORT with EBRT and then moved onto definitive IORT for qualified patients. Depending on the case, TARGIT-IORT can be used alone or as a targeted boost. With careful attention to eligibility criteria, this approach can provide an effective solution for those with early-stage breast cancer..

[Audio] The Weill Cornell Medical Center recently conducted a ten year study titled 'Second Chance IORT Lumpectomy for Recurrent Breast Cancer following Breast Conserving Therapy'. The study investigated the safety and effectiveness of intraoperative radiation therapy (IORT) as a form of radiation for breast cancer that had recurrent after an initial conserving therapy, like a lumpectomy. Results suggested IORT was a viable alternative with low recurrence rates. Moreover, the patients undergoing IORT had noticeably better cosmetic outcomes compared to those who received additional traditional external beam radiation. I will now explain the findings in more detail..

[Audio] Northern California breast cancer patients in special situations have access to an advanced treatment program from Fardeen Bhimani, MD and Valery Uhl, MD. The program is designed for those who have opted for a breast conserving lumpectomy for their cancer and have since experienced a local recurrence. Medical technology such as imaging and MRI is used to identify recurrences at an early stage and sentinel node biopsy may be employed if necessary. The program also provides a single dose Intrabeam by Carl Zeiss Intra-operative Radiation Therapy (IORT) to reduce the chances of recurrence. This treatment program is safe and effective and offers a second chance for those in special circumstances..

[Audio] Fardeen Bhimani, MD and Valery Uhl, MD are highly esteemed specialists in breast surgery and radiation oncology based in Northern California. They specialize in using TARGIT-IORT for special cases. A 10-year study that included 138 patients revealed that T1 tumors predominated, with 48% being DCIS, 42% IDC and 10% ILC. Of the 138 study participants, 8 experienced local recurrence - 5.7% of which were in the same quadrant and 5% contralaterally. Only 4 distal recurrences happened..

[Audio] Breast TARGIT-IORT is a revolutionary technology that allows for improved breast cancer treatments for those found to be in special situations. Fardeen Bhimani, MD and Valery Uhl, MD are two of the foremost experts in this technology, and specialize in providing highly effective breast surgery and radiation oncology services in Northern California. Their deep understanding and expertise of this technology ensures that patients in special situations are provided with the highest quality of care. This helps to reduce the risk of local recurrence, and can significantly improve patients' quality of life without the need for extensive, invasive surgeries.” At Fardeen Bhimani, MD and Valery Uhl, MD, patients in special situations can be confident that they will receive the most advanced treatments available. Their extensive knowledge of Breast TARGIT-IORT allows them to provide treatments with low rates of local recurrence and improved quality of life. This revolutionary technology is a powerful and reliable tool in breast cancer treatments, and Fardeen Bhimani, MD and Valery Uhl, MD are leaders in its implementation. With their help, many patients in special situations can have access to innovative and effective treatments..

[Audio] When it comes to breast augmentation, there are two distinct methods - pre or post-pectoral, and subglandular or submuscular. In the field of radiation oncology, these two approaches are especially crucial due to the high risk (50%) of contractures when radiation is applied. Thus, it is important to take note of the potential risks in order to make an informed decision with your doctor on which option is best suited for you..

[Audio] These patients all managed to develop contractures without undergoing radiation. The before and after images show that the one on the left had contracture on the right breast, whereas the one on the right had contracture on both breasts. Despite the risk of complications, these patients went ahead with plastic surgery and implants. Capsular fibrosis, commonly known as contracture, is caused by the formation of scar tissue that tightens and squeezes around the implant. This can happen shortly after the surgery, or even after some time has passed. However, the image on the far left shows that this contracture can be reversed..

[Audio] Fardeen Bhimani, MD and Valery Uhl, MD specialize in breast surgery and radiation oncology respectively in Northern California, with a focus on special situations for Breast TARGIT-IORT. An international study to analyze the role of IORT in augmented breast cancer was conducted and its results were published in Anticancer Research 39: 4215-4218 (2019) with a co-authorship of eminent researchers from Germany, U S A , Italy, U K and New Zealand. The insights gained from this advanced study is of great significance in comprehending the advantages of IORT for breast cancer patients..

[Audio] This study analyzed the safety of TARGIT-IORT in 16 breast cancer patients who had undergone implant-based breast augmentation. Results showed that TARGIT-IORT is a safe and feasible option during breast-conserving surgery, reducing the risk of capsular fibrosis. Our findings suggest that TARGIT-IORT may be a viable alternative to traditional external beam radiotherapy for patients with existing breast implants..

[Audio] Fardeen Bhimani and Valery Uhl have undertaken a research to discover how Breast TARGIT-IORT can be executed securely during breast conserving surgery after implant-based breast augmentation. Their research suggested no difficulties and no breast cancer-related events among the 16 observed patients. This study is a tribute to their skill and underlines the safe application of this technique in appropriate patients..

[Audio] The slide displays the result of a treatment that a patient had received from Dr. Uhl at our institution. It was a breast conserving surgery combined with breast augmentation and IORT, and a follow up one year later. The pictures on this slide portray the course of the treatment, beginning with the IORT treatment in March 2017 up to the follow up in April 2018. Unfortunately, the patient relocated and we had lost contact with her. Nevertheless, this slide displays the amazing progress that she made after her treatment..

[Audio] We are going to be discussing a significant medical matter: the consequences of radiotherapy doses on cardiac pacemakers. In 1994, the American Association of Physicists in Medicine Task Group 34 identified that a cardiac pacemaker can malfunction at radiotherapy doses as reduced as 10 Gy. Additionally, it was established doses of 2 Gy could lead to substantial functional fluctuations. Because of this, guidelines recommended capping the dose to the pacemaker to 2 Gy. With much to go over about this subject, let's begin..

Ipsilateral Pacemaker. [image] Pacemaker.

[Audio] When it comes to radiotherapy for patients with implanted cardiac devices, there have been a great level of research conducted over the years and many case reports published about the effects of radiation on modern implantable cardiac devices, and how to manage patients before, during, and after their radiotherapy, as per AAPM TG-34 published in 1994. As medical professionals, it is crucial to be aware of the significance of this type of research and how it can help to provide effective radiotherapy..

[Audio] Patients may require a procedure to move the pacemaker (PM) which carries certain risks. The task group has provided crucial advice to prevent the use of neutron-generating treatments and to ensure the total dose to the PM does not exceed two Gray for pacing-dependent patients and five Gray for pacing-independent patients. Fardeen Bhimani and Valery Uhl, specialists in breast surgery and radiation oncology, are able to provide special considerations in Breast TARGIT-IORT..

[Audio] Fardeen Bhimani and Valery Uhl are renowned surgeons who specialize in breast surgery and radiation oncology in Northern California. They possess an impressive level of expertise specifically for Breast TARGIT-IORT (Targeted Intraoperative Radiation Therapy), a relatively new form of radiotherapy. Before therapy, a chest x-ray is taken to estimate the positioning of the breast cancer, followed by a thin lithium fluoride detector, or TLD, being placed on the edge closest to the IntraBeam applicator. After that, a dose of 0.08 Gy is administered. A study published in Radiation Oncology 2012: 7: 128 proved that this form of targeted radiation therapy is a viable option in this situation..

[Audio] Pacemakers and radiation therapy can be complicated. There are risks of permanent damage from the ionizing radiation of EBRT and interference with the pacemaker’s electronic circuit or magnetic reed switch. In these cases, physicians may need to relocate the pacemaker away from the radiation field either to the contralateral side or into the neck pocket, which carries the risk of lead extraction. It is important to be aware of the complexity of these situations so that the best decision can be taken for the safety and well-being of the patient..

[Audio] Fardeen Bhimani, MD and Valery Uhl, MD specialize in breast surgery and radiation oncology respectively in Northern California. With their focus on specific situations involving Breast TARGIT-IORT, they are capable of providing a secure and efficient treatment. This treatment uses a low energy, 50 kVp to decrease radiation exposure to neighbouring tissues. The shortened length of the treatment also adds to patient compliance; furthermore, relocation of pacemaker is unnecessary which makes the entire process less intricate. As such, it is possible to give the same standard treatment without increasing any extra complexity..

[Audio] Fardeen Bhimani, MD, and Valery Uhl, MD specialize in breast surgery and radiation oncology in Northern California. They have special experience in dealing with cases that involve both breast cancer and pacemakers. They have the ability to provide personalized treatments that involve Breast TARGIT-IORT, giving patients the best care possible for both medical conditions..

[Audio] Our case report examines the use of intraoperative radiotherapy, namely TARGIT-IORT, for patients with pre-installed pacemakers. The research team comprised of breast surgeons, radiation oncologists, and medical experts from the United States. The team studied whether TARGIT-IORT could be used as a safe and effective option for treating breast cancer in patients with pacemakers. The findings demonstrate that TARGIT-IORT may be a viable safe and effective way to treat breast cancer, while reducing the risk of complications in patients with pacemakers..

[Audio] Dr. Bhimani and Dr. Uhl have created a program that specializes in a treatment called TARGIT-IORT (Targeted Intraoperative Radio Therapy for Breast Cancer). This treatment is an advanced approach that combines Lumpectomy surgery and radiation therapy, thus allowing a patient to receive radiation therapy during the same surgery that removes the cancerous tumor. This process reduces or even eliminates the need of traditional radiation treatments, resulting in shorter recovery periods and fewer side effects. This article will focus on two cases where the procedure was used to treat female patients with an implanted dual-chamber pacemaker who had been diagnosed with invasive ductal carcinoma on the left side. Both patients met the requirements for IORT, which is being done in a registry trial. Upon the wide excision lumpectomy, both patients underwent IORT and the results were positive. Currently, the patients are in the process of recovering from the procedure. This serves to underscore the significance of specialized medical care for complex medical conditions, as well as how innovative treatments such as TARGIT-IORT can offer viable solutions for these patients..

[Audio] An 82 year old female patient presented with a lump in her left breast. Mammography showed a 10 mm spiculated mass, and an ultrasound-guided core biopsy revealed it to be an invasive ductal carcinoma. Fardeen Bhimani and Valery Uhl, experts in breast surgery and radiation oncology, employed their TARGIT-IORT technique, placing a 40-mm diameter spherical applicator 10 cm away from the primary tumor and delivering a dose of 20 Gy in 25 minutes. The procedure was successful, with no pacemaker issues, showcasing the expertise of both doctors in safely delivering a radiation treatment for breast cancer..

[Audio] Fardeen Bhimani, MD and Valery Uhl, MD specialize in breast surgery and radiation oncology in Northern California, focusing on special situations for Breast TARGIT-IORT. A 64-year-old woman with a history of right invasive lobular carcinoma treated with SX and whole breast radiation therapy had an incidental finding of a 7 millimeter spiculated mass at the 12:00 axis of the left breast on a routine follow-up mammogram, which was diagnosed as clinical stage I T1 (7 mm) N0 grade 2, ER +, PR + Her2 – invasive ductal carcinoma and a focal ductal carcinoma in situ (DCIS). As the patient had a pacemaker which was 10 centimeters away from the primary tumor, the doctors decided to carry out a lumpectomy followed by targeted intraoperative radiation therapy with a 35-millimeter diameter spherical applicator, with 20 Gray doses given for 16 minutes. The successful procedure was concluded without any pacemaker complications, which has already been observed in prior cases, proving the safety of IORT treatment in patients with pacemakers..

[Audio] Fardeen Bhimani and Valery Uhl are specialists in breast surgery and radiation oncology respectively in Northern California with a focus on special cases related to Breast TARGIT-IORT. Our findings show that this procedure is an effective and secure alternative for patients with invasive ductal carcinoma and pacemakers. We found no device malfunction or breakdown before, during, or after the surgery, demonstrating the safety of IORT for these patients. With the majority of device suppliers pointing out that their devices can deal with radiation doses from 1 to 5 Gy, IORT is a suitable solution to both give enough radiation to the tumor bed and prevent pacemaker malfunction. However, the effects of IORT on pacemakers at distances less than 10 cm were not explored in our study and further investigation in that direction is needed to verify the safety and usefulness of IORT in such situations..

[Audio] A study examined the radiation exposure to pacemaker devices when using intraoperative radiation therapy (IORT) in breast cancer patients. It was found that the radiation exposure decreased with an increased distance between the applicator and the pacemaker. Additionally, no pacemaker malfunctions or failures occurred, not even when the dose was raised to 10-20 Gy. This data is significant for medical professionals taking into account IORT as an alternative treatment for breast cancer patients with a pacemaker..

[Audio] When treating patients with bilateral breast cancer, the cases are complex and require special attention. Additionally, those undergoing EBRT for BBC have a two-fold increased risk of complications. Therefore, Fardeen Bhimani and Valery Uhl, who specialize in breast surgery and radiation oncology in Northern California respectively, focus their efforts on special cases of Breast TARGIT-IORT..

[Audio] Patients undergoing breast-conserving surgery often need adjuvant radiation therapy. But the use of external beam radiation therapy (EBRT) can have some potential downsides. These include an increased risk of non-breast cancer-related mortality, as well as secondary cancers and heart diseases. Additionally, poor cosmesis, poor patient-reported outcomes in terms of breast-related quality of life and overall quality of life, as well as a geographical miss of the lumpectomy cavity site due to post-surgical changes, can be associated with EBRT." EBRT is often used to treat patients undergoing breast-conserving surgery. But it is important to be aware of potential risks associated with its use, including an increased risk of secondary cancers and heart diseases such as ischemic heart disease and pericarditis. Poor cosmesis, as well as poor patient-reported outcomes in terms of breast-related quality of life and overall quality of life, are also associated with EBRT. Furthermore, due to post-surgical changes, it may result in a geographical miss of the lumpectomy cavity site..

[Audio] IORT provides numerous advantages when used in breast cancer patients. It reduces non-breast cancer-related mortality, including cardiovascular causes, and in smokers, it may reduce the risk of secondary lung cancers which are often linked to EBRT. IORT has the advantage of targeting the lumpectomy cavity intraoperatively, which eliminates inaccuracies due to tissue rearrangement. Additionally, IORT can lead to higher patient compliance as a result of its shorter treatment duration and fewer visits, leading to a better patient experience. Other advantages of IORT include better cosmesis, improved patient-reported outcomes associated with breast-related quality of life and overall quality of life, and nearly zero geographical miss..

[Audio] Fardeen Bhimani and Valery Uhl are renowned medical experts in breast surgery and radiation oncology respectively, based in Northern California. They focus on particular circumstances linked to a kind of breast treatment called TARGIT- IORT. This paper presents a case in which the patient experienced a bilateral procedure involving targeted intraoperative radiotherapy. The results of this research demonstrate that this form of treatment is secure and successful when executed by specialists..

[Audio] At the Northern California office of Fardeen Bhimani, MD and Valery Uhl, MD, we have been using intraoperative radiation therapy (IORT) to treat early-stage breast cancer with promising results. In our case series of five patients, all five received IORT as part of their treatment, with no evidence of disease at the 36 month follow up. We are pleased to offer this safe and highly effective treatment option for early-stage breast cancer patients." At Fardeen Bhimani, MD and Valery Uhl, MD, we are dedicated to offering the latest treatments to our patients with early-stage breast cancer. Our case series of five patients demonstrates that intraoperative radiation therapy (IORT) is a safe and effective treatment option for early-stage breast cancer that is well tolerated by our patients. During surgery, all patients received IORT and none of the patients had any evidence of disease at the 36 month follow-up. We are committed to offering our patients the best possible outcomes and are proud of the results our case series has achieved..

[Audio] Our research suggests that Intraoperative Radiation Therapy (IORT) is a valid, cost-effective and safe option for patients facing breast cancer-related issues. In our study, no patients developed any complications, indicating the feasibility of using IORT for breast cancer-related surgery. This technique offers the patient better compliance and fewer visits, which provides an advantage. We recommend further studies to investigate the use of IORT for breast cancer cases..

[Audio] The table presented here provides valuable information about the cases of five different patients, all of them treated with the TARGIT-IORT technique for breast cancer. The data includes the age of the patient, the final pathology, the pathological size and tumor size of the right and left side for each patient, the applicator size used and the adjuvant therapy. We can observe that in three of the five cases the treatment did not require additional radiation with external beam and no complications were reported..

[Audio] Fardeen Bhimani MD and Valery Uhl MD are healthcare specialists in Northern California, with a focus in breast surgery and radiation oncology. One of their specialties is Breast TARGIT-IORT, which offers many advantages. Patients have a lower risk of radiation exposure to areas outside the target field, as well as a reduced risk of skin reactions from radiation for those with larger breast volumes. Furthermore, IORT significantly reduces the chance of the heart receiving any significant dose of radiation, especially in cases of left-sided breast cancer and cardiovascular concerns. Because of these advantages, Breast TARGIT-IORT is an ideal choice for many patients in Northern California..

[Audio] Recent research and techniques in radiation oncology have revealed a safe dose threshold that can help reduce the risk of cardiovascular complications. Fardeen Bhimani, MD and Valery Uhl, MD specialize in breast surgery and radiation oncology in Northern California, respectively, and specialize in particular situations of Breast TARGIT-IORT therapy. This treatment offers a highly targeted and customized approach to radiation therapy that minimizes the spread of radiation to the heart and lungs, with the goal of ensuring a safe dose threshold to reduce the risk of cardiovascular complications..

[Audio] IORT is a special situation for breast cancer treatment due to the iso-dose lines of a left-sided breast cancer when treated with IORT versus External Beam Radiation Therapy (EBRT). On the EBRT image, it is evident that the radiation decreases with distance, and that 5% of the iso-dose still has scatter making it along the heart. With IORT, it is evident that the beam is attenuated by soft tissue and the ribs and muscles, and 80% of the dose is absorbed by two centimeters. This means external beam radiation has a much wider dose drop-off than IORT, which results in much less radiation reaching the heart, and consequently, significantly less cardiovascular damage and concerns..

[Audio] Radiation treatment can have a drastic effect on the skin of individuals with large breast volume, resulting in a condition known as radio-desquamation. To minimize skin reactions, our patients are advised to keep their skin dry and cool. In more serious cases, Dr. Uhl recommends applying corn starch under the breast and in the axilla area five times a day for smoothness and reduced friction. Although the treatment can be difficult and uncomfortable, it has been found to be effective in aiding healing. For worse cases, Demboro may be needed four times a day to dry out the area, even if it is unpleasant and messy..

[Audio] We are talking about Fardeen Bhimani, MD and Valery Uhl, MD specializing in breast surgery and radiation oncology in Northern California. The focus of this presentation is on special situations for TARGIT-IORT. To illustrate this, a case study of Dr. Cal Ridgeway's patient is provided. Four weeks post-operative, her results are impressive with very little skin irritation, significantly less pain compared to other treatments, and improved cosmesis. For those with large breast volumes, TARGIT-IORT is significantly easier, and patient outcomes are more successful with this treatment..

[Audio] The group analyzed the radiation scatter seen elsewhere and found that the radiation delivered to organs at risk such as the heart, lungs, and spine through IORT was always lower than the recommended guidelines. APBI was around 2-5 times greater than IORT and EBRT delivered a maximal dose of 10.4 Gy to the contralateral breast and 53 Gy to the ipsilateral lung. The estimated risk for secondary cancer in these organs after IORT and APBI was lower than EBRT..

[Audio] Our conclusions indicate that Intraoperative Radiation Therapy (IORT) is a safer option than Accelerated Partial Breast Irradiation (APBI) and External Beam Radiation Therapy (EBRT). Aziz et al. concluded in their 2011 study, published in Radiation Oncology, that the risk of secondary cancer induction is lower with IORT due to its ability to deliver a higher dose within a smaller volume of tissue. Thus, IORT may be the preferable treatment option for those looking to treat their cancer while minimizing potential side effects..

[Audio] The analysis of the results indicates that TARGIT-IORT leads to a lower number of deaths from cardiovascular diseases, lung problems, and other cancers. This decrease is significant, with a relative reduction of 41% and an absolute reduction of 4.4% at 12 years. Let us now look at the next slide..

[Audio] Fardeen Bhimani and Valery Uhl specialize in breast surgery and radiation oncology in Northern California and focus on breast target intraoperative radiation therapy, or TARGIT-IORT. Research showed that when a patient develops local recurrence after external beam radiation therapy, or EBRT, there is a 35% chance that the patient already has metastasis. Conversely, if the patient develops recurrence after IORT, the risk of metastasis is significantly reduced and is similar to the risk of a patient who had no recurrence..

[Audio] Smokers are at an increased risk of developing secondary lung cancer following breast radiation therapy. As treating physicians, it is our duty to inform these patients of the potential dangers and to consider the use of IORT when weighing radiation treatment options, due to its lower radiation doses compared to the more commonly used WBI. This lessens the risk of secondary lung cancer and reduces radiation toxicity. Additionally, we encourage our patients to quit smoking in order to further reduce the threat. With the proper guidance and treatment, we can guarantee that our patients receive the best care and treatment available..

[Audio] Fardeen Bhimani and Valery Uhl are two specialized medical doctors who practice in Northern California, focusing on breast surgery and radiation oncology, particularly for special situations. They utilize one of the technologies TARGIT-IORT, an excellent way to protect healthy tissue from unwanted radiation. This procedure has some major advantages, such as no delay in radiation which helps prevent tumor cell proliferation, no compliance issues or geographical misses, improved workflow in busy radiation oncology departments, and it can be done with reductions and oncoplastic closure..

[Audio] TARGIT-IORT is a revolutionary approach to the treatment of breast cancer that reduces the need for surgery, chemotherapy, and radiation, while offering our patients a better quality of life and less risk of complications. The following slide will illustrate why sometimes less can be more effective..

[Audio] Fardeen Bhimani, MD and Valery Uhl, MD specialize in breast surgery and radiation oncology with a focus on special situations for Breast TARGIT-IORT in Northern California. The photo truly captures the dedication these two doctors have to their craft and the patients they serve. Enjoyment of this presentation is appreciated. Thank you..