1. Photodynamic Therapy for breast cancer
Ron R. Allison, M.D. Medical Director 21st Century Oncology 801 WH Smith Blvd. Greenville NC USA

2. Why PDT for breast cancer
PDT has wide ranging success for   various cutaneous lesions
PDT offers excellent cosmesis
PDT is non- carcinogenic
PDT part of a multidisciplinary approach

3. Clinical applications
Primary therapy   - PD/PDT   - post excision for margins
Salvage Therapy  - Chest wall recurrence  - metastatic lesions (of bone)

4. Clinical applications
Primary disease: No peer reviewed publications
Salvage Therapy: Multiple publications

5. PDT- Chestwall Failure From Breast Cancer
ECU Experience: R. Allison, R. Cuenca, G. Downie, C. Sibata

6. 95 % DFS in advertisements…
How about the forgotten 5%?

7. Chestwall Failure Physiologic
Lesions are painful, bleed, become infected, itch
Dermal lymphatics spread everywhere
Psychologic
Watch tumors grow
QOL stinks

8. Initial Salvage Surgery for XRT failure XRT for surgical failure
Chemo- as chestwall failure bodes for systemic disease

9. However, a significant number of pts have continued chestwall failures despite several salvage attempts…
Surgery :Chestwall resections & reconstructions
: 90% failure at surgical borders
XRT : Maximum dose is a reality
: Rib fx, fibrosis, pneumonitis
Chemo : 3rd line agents don’t give CR on chest wall

10. PDT for Chestwall Works on cutaneous malignancies
Literature shows good cosmetic and tumor response
Does not stop other therapies
Outpatient
Minimal tx toxicity/discomfort
Repeatable

11. Clinical PDT for Chestwall 2 Distinct Systems:
High drug and lower light dose (directed at tumor)
Low drug and higher light dose (not as directed at tumor as you think)

12. High Drug/Lower Light High Drug Normal Tumor Normal 0 0 0 0 0 0 0 0

13. Lower Drug/High Light Low Drug Normal Tumor Normal 0 0 0 0 0 0 0 0

14. Significant Morbidity
Clinical Trials
Author N
Drug
Light(J/cm2)
Response
Significant Morbidity
Bandermonte 4
3mg
120
75%
RPCI 6
2 mg 75
1 mg
150
25%
0.6 mg
30-240 0%
Allison/Mang 9
0.8 mg
90%
Taber 7
100
50%
ECU 14
1 pt

15. Chestwall PDT 50 Women with biopsy proven chestwall disease Age 43-70
No pt. lost to follow-up
Range 3-18 months

16. Initial Treatment Mastectomy and Chemo/Hormones:
Lumpectomy + XRT + Chemo/Hormones:
1st Failure
Mastectomy:
XRT:
Chemo:
2nd Failure
Surgery:

17. At Presentation at ECU 44 pts on narcotic analgesics
40 pts with itching lesions
20 pts with open wound due to tumor
All were progressing on chemotherapy
45 systemic mets (asymtomatic in all)

18. PDT Photosensitizer : Off label Photofrin, 0.8 mg/kg
Illumination : 632 nm diode laser
Tx Protocol : 0.8 mg/kg Photofrin followed 48 hrs later by outpt illumination at 150 J/cm2

19. PDT Treatment 2215 lesions treated Outpatient therapy
Sessions of 3-6 hours
Ice patches used if illumination caused tenderness

20. Results 91% CR- Defined as total lesion elimination with healing
9% PR- Defined as >50% reduction in lesions size without growth
Minimum f/u 3 months (median=9 months)

21. Treatment Findings
All pts underwent outpatient therapy w/o complications
All therapy given as prescribed
No photosensitivity reaction
Pain control is excellent
Itching and symptoms removed

22. Conclusions PDT is well tolerated Response is excellent
Morbidity is acceptable
The drug and light dose used offers good outcome
PDT does not stop additional therapy if needed.

23. Summary PDT can offer excellent palliation Outpatient procedure
Pts who have had extensive surgery, XRT and chemo can respond well and heal
Use PDT earlier in treatment course

24. Treatment Day
3 months followup

37. Other PS used for breast cancer
* Purlytin Allison: 9pts, 1.2 mg/kg, 90% CR, minimal morbidity
* Foscan Wyss: 7pts, 0.15 mg/kg, 90% response, 90 % morbidity (tissue slough)
*Phthalocyanine (Pc4) Oleinick: 2pts, .135 mg/m2, Minimal response
*Motexafin Lutetium Hahn: 5pts, 5 mg/kg, morbid

38. Breast Surg, XRT: Excellent local control
PDT to lumpectomy bed + XRT to breast
PDT to lumpectomy bed alone!
PDT to chestwall even in heavily pre-txd tissue: Excellent local control and cosmesis
PDT for Dx via fluorescence
Many questions on dose, timing, and technique
Immune modulation via PDT?!