Sparender bestraling van de axilla?

Meer sparend bestraling van de axilla?
Less is more (than enough)
Nicola Russell
Techniek tot nu toe
Conventionele simulatie
Virtuele simulatie
Techniek voor okselbestraling
Klier levels I‐III
Plexus brachialis
Planning
Acute bijwerking: huid epidermolyse
periclaviculair
Sub-acute bijwerking: stralingspneumonitis
In periclav veld
<1% kans bij mamma RT alleen
4-5% kans bij mamma + oksel RT
Late bijwerkingen: Armoedeem
Primary axillary radiotherapy as axillary treatment in breast-conserving therapy
for patients with breast carcinoma and clinically negative axillary lymph node
Hoebers et al. Cancer 2000;88:1633-1642
105 patients, 55 prospective FU
Prospectively scored, arm edema was reported subjectively by the patient in 4%
and objectively measured in 11% of cases (n=55).
Is radiation alone adequate treatment to the axilla for patients with limited axillary
surgery? Implications for treatment after a positive sentinel node biopsy.
Galper et al. Int. . Radiat.Oncol Biol Phys 2000;48: 125-132
292 without axillary surgery + 126 patients with limited axillary dissection
Moderate –severe Arm oedema in 1.2% (5 patients) persistent in 4 patients
Schouderfunctie
Primary axillary radiotherapy as axillary treatment in breast-conserving therapy
for patients with breast carcinoma and clinically negative axillary lymph node
Hoebers et al. Cancer 2000;88:1633-1642
105 patients, 55 prospective FU
Impaired shoulder function was reported subjectively in 35% and objectively
measured in 17% of cases.
No brachial plexus neuropathy was noted.
Is radiation alone adequate treatment to the axilla for patients with limited axillary
surgery? Implications for treatment after a positive sentinel node biopsy.
Galper et al. Int. . Radiat.Oncol Biol Phys 2000;48: 125-132
292 without axillary surgery + 126 patients with limited axillary dissection
1.2% transient brachial plexopathy (resolved without treatment)
Zeer late bijwerking:
schoudergordel spieratrofie
RT oksel en periclaviculair rechts in 1989, links in 2004
(Foto 2010)
Spier en bot in okselveld
Plexus brachialis
humeruskop
scapula
Tumorcontrole
Primary axillary radiotherapy as axillary treatment in breast-conserving therapy
for patients with breast carcinoma and clinically negative axillary lymph node
Hoebers et al. Cancer 2000;88:1633-1642
105 patients
No isolated axillary lymph node recurrence was observed. In two patients, axillary
recurrence was accompanied by distant metastases.
Is radiation alone adequate treatment to the axilla for patients with limited axillary
surgery? Implications for treatment after a positive sentinel node biopsy.
Galper et al. Int. . Radiat.Oncol Biol Phys 2000;48: 125-132
292 without axillary surgery + 126 patients with liited axillary dissection
1.4% (6 patients) axillary recurrence, 4 with simultaneous distant metastases
Doelgebied?
Is het nodig om de gehele oksel en periclaviculaire
kliergebied te bestralen bij SN+ tumoren?
Aantal axillaire klieren in AMAROS trial
Median age
Menopausal status
pT stage
SNB results
ALND arm (n=300)
RT arm (n=266)
56
55
pre 88 (29.3) 93 (35.0) peri
19 (6.3) 20 (7.5) post
176 (58.7) 142 (53.4) <= 1 cm 30 (10.0) 33 (12.4) 1<‐2 cm 162 (54.0) 141 (53.0) 2<‐3 cm 90 (30.0) 84 (31.6) 3<‐5 cm 17 (5.7) 7 (2.6) >5 cm 1 (0.3) 1 (0.4) macro 182 (60.7) 175 (65.8) micro 78 (26.0) 59 (22.2) ITC
32 (11) 31 (12) pN stage
1‐3 nodes
4‐9 nodes
10+ nodes
261 (87.0) 25 (8.3) 12 (4.0) NA
NA
NA
Histology
ductal lobular
Others I II III BCT MST
216 (72.0) 39 (13.0) 45 (15.0) 66 (22.0) 141 (47.0) 85 (28.3) 260 (86.7) 37 (12.3) 198 (74.4) 31 (11.7) 37 (13.9) 64 (24.1) 120 (45.1) 77 (28.9) 238 (89.4) 28 (10.5) Grade
Surgery
Kans op verdere klieren in de oksel bij SN+
Voorbeeld: Patiente 54 jaar, mammacarcinoom rechts
WLE en SNP
PA:
1,3 cm IDC graad 1
1 SN met macrometastase
1 SN tumorvrij
1 non-SN tumorvrij
Dus 1/3 klieren +
http://www.mskcc.org/applications/nomograms/breast/BreastAdditionalNo
nSLNMetastasesPage.aspx
Kans op verdere klieren in de oksel bij SN+
Voorstel
Voor laag risico ziekte alleen bestraling van de “chirurgische oksel” (levels I en II)
Voorstel
Voor laag riscio ziekte alleen bestraling van de “chirurgische oksel” (levels I en II)
In POWER studie voorstel:
Bij risico op aanvullende klier metastasen tussen 10‐40%:
randomisatie tussen oksel behandeling vs observatie.
Okselbehandeling na keuze óf chirurgie óf radiotherapie
Dan radiotherapie op hetzelfde doegebied als de chirurg.
Voordeel: minder bijwerkingen, acute huidreactie, pneumonitis, schouderfunctieverlies en mogelijk oedeem.
Minder overbehandeling!