“ “ Help, de Help, de richtlijn richtlijn laat laat me in de me in de steek steek ! ! ” ” radiotherapie radiotherapie Nederlands Kanker Instituut/ Antoni van Leeuwenhoek Amsterdam Paula Elkhuizen 28 oktober 2009
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““Help, de Help, de richtlijnrichtlijn
laatlaat
me in de me in de steeksteek!!”” radiotherapieradiotherapie
Nederlands Kanker Instituut/Antoni
van Leeuwenhoek
Amsterdam
Paula Elkhuizen28 oktober
2009
Radiotherapie issues
•
Boost-
no
boost?
•
Whole
breast
/partial
breast
•
Post mastectomie RT
•
RT na neoadjuvante
chemotherapie;
Relatie
Locale controle-Overall Survival
prevention
of 4 LR’s prevents
1 cancer
death
Radiotherapie issues
•
Boost-
no
boost?
•
Whole
breast
/partial
breast
•
Post mastectomie RT
•
RT na neoadjuvante
chemotherapie;
Dose
Response for
local
control
after
WLE and RT
Bentzen IJROBP 2004
4 % gain
in LC
0
10
20
30
40
50
0 1 2 3 4 5 6 7 8 9 10
Age < 40 (n=448)
0
10
20
30
40
50
0 1 2 3 4 5 6 7 8 9 10
Age 41-50 (n=1334)
0
10
20
30
40
50
0 1 2 3 4 5 6 7 8 9 10
Age 51-60 yr (n=1801)
0
10
20
30
40
50
0 1 2 3 4 5 6 7 8 9 10
Age > 60 yr (n=1734)
P=0.0019 P=0.0096
P=0.0012 P=0.029
Local failure by age: Boost versus No Boost
Bartelink 2007 JCO
standard treatmentadditional treatment
CBO-richtlijn
Een boost naast radiotherapie van de gehele mamma verbetert de locale controle in alle patiënten.
Het absolute voordeel van een ‘boost' na complete resectie neemt af met de leeftijd van patiënte.
Niveau 1: A1 Bartelink 2001, Bartelink 2007
In de praktijk
•
Afspraak boost tot bepaalde leeftijd
•
Benefit/ cost; fibrose, dosis mamma, hart, longen
•
Indicatie boost obv
andere (risico)-factoren:–
Snijranden
–
Gradering–
LVI
–
DCIS–
Co-morbiditeit
Radiotherapie issues
•
Boost-
no
boost?
•
Whole
breast
/partial
breast
•
Uitbreiding post mastectomie RT
•
RT na neoadjuvante
chemotherapie;
Partial breast irradiation (PBI): rationale•
Most recurrences after BCT close to the tumor: 70-80%
Vicini
et al 2007
5 -
10 yrs LR rates 1.6% -
3.8%
Polgar
et al 2007; fase IIIWBI or PBI (n=285)5 yrs LR rates 3.4% and 4.7% ns
Many randomised
studies are running•
Low risk patients; (>50-60 jr, negative margins etc)
•
NL:–
IRMA trial; (PBI (3dCRT) vs whole
breast
RT)–
PAPBI trial; neoadjuvant
RT
Radiotherapie issues
•
Boost-
no
boost?
•
Whole
breast
/partial
breast
•
Post mastectomie RT
•
RT na neoadjuvante
chemotherapie;
Post-mastectomie indicatiesRT indien high risk:
–
cT4 en/of cN3–
Irradicaliteit
–
pN
4+
RT bij intermediate
risk?–
N1-3
–
pN0 met risicofactoren•
Leeftijd < 40 jaar
•
Lymfangioinvasie•
Graad III
pN0 pN1-3 pN4+
Local
Recurrence;
EBCTCG data; Mastectomy
+ AC (axillary clearance) with(out) RTunpublished results
pN0 pN1-3 pN4+
All Cause
mortality;
Mastectomy
+ AC (axillary clearance) with(out) RTEBCTCG data
unpublished results
SUPREMO (BIG 2-04 EORTC 22051-10052 BOOG 2006-03)
Selective Use of Postoperative Radiotherapy aftEr MastectOmy
Stage II breast cancer after mastectomypT1-2 N1 M0
pT2 N0 M0 gr III or LVIR
Chest wall radiotherapy (50 Gy)
No chest wall radiotherapy
Main end-point:
Overall survival
Presentator
Presentatienotities
International consensus supports routine use of PMRT in T3 tumours or 4 or more involved auxiliary nodes (or 20% or greater risk of loco regional recurrence, LRR, at 10 years). Role of chest wall RT in women with 1-3 involved nodes (<15% risk of LRR at 10 years) is uncertain. Oxford overview (2000) suggests PMRT reduces breast cancer mortality in women with 20% 10 year risk of LRR by 5%. Danish and Canadian trials show 9 – 10% survival advantage from addition of comprehensive loco-regional RT to systemic therapy. Danish trial showed 8% gain in 10 year overall survival (62% vs. 54%) in 1-3 N+ group. However, surgery of the axilla inadequate in Danish trial (mean 7 nodes) generalisability of findings unclear. Systemic therapy changed from CMF to anthracycline containing required for ‘intermediate risk’ group.
Radiotherapie issues
•
Boost-
no
boost?
•
Whole
breast
/partial
breast
•
Post mastectomie RT
•
Neoadjuvante
chemotherapie;
RT na neoadjuvante
chemotherapie‘standaard’
RT indicaties gebaseerd op postop informatie
•
RT indicatie obv
pre-chemo
cTNM–
pre-chemo
RT consult–
N status•
axillair: pre-chemo
SN•
cN+; periclav
N+?
•
RT indicatie obv
post-chemo
info –
Histologie veranderd •
Gradering•
LVI–
N status
•
Downstaging
invloed op RT indicatie?
RT na neoadjuvant
chemotherapie
In de praktijk:•
MSO–
kliergebieden?
•
Postmastectomie:–
High risk T3-4N+; •
RT ongeacht respons
–
Intermediate
risk….?•
cT1-2N1
RT na neoadjuvant
chemotherapie
Door onvoldoende info pre-chemo, En ‘veranderde’
info post-chemo
RT Indicatie?–
overbehandeling
–
onderbehandeling
Intermediate
risk cT1-2N1•
Neo
SUPREMO
•
NL studie voorstel (Boersma, Elkhuizen, Voogd)–
richtlijn bij neoadj
CT
–
Registratie studie
Radiotherapie issues
•
Boost-
no
boost?
•
Whole
breast
/partial
breast
•
Post mastectomie RT
•
Neoadjuvante
chemotherapie;
RT Indicatie
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