חידושים בטיפול קרינתי לשד: חידושים בטיפול קרינתי לשד: קרינה מקוצרתקרינה מקוצרת

,,דיאנה מצייבסקידיאנה מצייבסקימחלקה אונקולוגית, מחלקה אונקולוגית,

מכון קרינהמכון קרינה24.04.13

External beam radiotherapy External beam radiotherapy

Whole Breast Whole Breast RadiotherapyRadiotherapy

(WBRT)(WBRT)

Standard tangential fieldStandard tangential field

SimulationSimulation

Radiotherapy For Breast Cancer Radiotherapy For Breast Cancer Increases Heart Disease RiskIncreases Heart Disease Risk

N Engl J Med 2013; 368:1055-1056March 14, 2013

FATIGUEFATIGUE

RADIATION DERMATITISRADIATION DERMATITIS

RADIATION DERMATITISRADIATION DERMATITIS

Changes in breast appearanceChanges in breast appearance

Rib fracturesRib fractures

LYMPHEDEMALYMPHEDEMA

Conventional Whole breast Conventional Whole breast Radiotherapy planRadiotherapy plan

Boost

25 fractions 8 fractions2Gy per fraction

FASTER, FASTER!

The UK standardisation of Breast The UK standardisation of Breast Radiotherapy (START)-Radiotherapy (START)-

Trial A and B of Radiotherapy Trial A and B of Radiotherapy hypofracyionation for treatment hypofracyionation for treatment

of early breast cancer: of early breast cancer: a randomized triala randomized trial

HypofractionationHypofractionation

««STARTSTART»» 2525 х 2 х 2 GyGy = 15 х 2,67 = 15 х 2,67 GyGy

STARTSTART

Randomization

50 Gy -

in 25 fractions

40 Gy -

in 15 fraction

1105 1110

HypofractionatedHypofractionatedRadiation Therapy for Breast Radiation Therapy for Breast

CancerCancer

RANDOMIZATION

50 Gy in 25 fractions

42,5 Gy in 16 fractions

612 622

Shorter fractionation Shorter fractionation schedules: schedules:

■■No difference in local recurrenceNo difference in local recurrence■■No difference in overall survival No difference in overall survival ■■A significant decrease in acute A significant decrease in acute radiation toxicityradiation toxicity■■No difference in late skin toxicity, No difference in late skin toxicity, ischemic heart disease, or rib fracturesischemic heart disease, or rib fractures■■No difference in breast appearance No difference in breast appearance

What still is questionable?What still is questionable?

The effect not clear in large breasts The effect not clear in large breasts The safety of shorter course in The safety of shorter course in

combination with chemotherapy or combination with chemotherapy or monoclonal antibodies (Herceptin, monoclonal antibodies (Herceptin, Pertuzumab)?Pertuzumab)?

The “boost” issueThe “boost” issue What about treatment for regional What about treatment for regional

lymph nodes ?lymph nodes ?

Reasonable approach Reasonable approach (supported by ASTRO/ESTRO)(supported by ASTRO/ESTRO)

Women >50yWomen >50y Tumor < 5 cmTumor < 5 cm Node negativeNode negative Without prior chemo?Without prior chemo? Boost?Boost?

Partial Breast IrradiationPartial Breast Irradiation

Rationale for Partial Breast Rationale for Partial Breast IrradiationIrradiation

~ 80% of local ~ 80% of local recurrences after recurrences after conservative surgery conservative surgery + WBRT occur in + WBRT occur in tumor bed regiontumor bed region

““Elsewhere” Elsewhere” recurrences in recurrences in breast rare after CS breast rare after CS +/- WBRT+/- WBRT

Partial Breast RadiotherapyPartial Breast Radiotherapy

Interstitial Breast Brachytherapy

5 days-2 daily fractions

Mammosite

Intra-operative radiotherapyIntra-operative radiotherapy

External Beam Partial Breast Irradiation

PBI: Where are we?PBI: Where are we?

While several preliminary studies While several preliminary studies have had excellent 5-yr results, have had excellent 5-yr results, they contain only small numbers they contain only small numbers of highly-selected ptsof highly-selected pts

NSABP B-39/RTOG : 10 yrs for NSABP B-39/RTOG : 10 yrs for data to mature data to mature

Consensus Statements on PBI: Consensus Statements on PBI: American Society of Breast Surgeons American Society of Breast Surgeons and American Brachytherapy Society.and American Brachytherapy Society.PBI “off protocol” should be limited to pts:PBI “off protocol” should be limited to pts:

age > 50age > 50

IDC histology or DCISIDC histology or DCIS

Tumor Tumor << 2 cm (including DCIS) 2 cm (including DCIS)

Margin Margin >> 2 mm 2 mm

Lymph node - negativeLymph node - negative

Partial Breast Irradiation: Partial Breast Irradiation: Not Yet the Standard-of-Not Yet the Standard-of-

CareCare