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Instituto Nacional de Cancerología RADIOTERAPIA EN CÁNCER CÉRVICO UTERINO DR. RAYMUNDO HERNÁNDEZ MONTES DE OCA R3 FACTORES QUE AFECTAN LA RESPUESTA A RADIOTERAPIA • Tiempo de protracción. • • Debe ser inferior a 8 semanas (56 días). Reducción de 0.5% a 1% en SCE y control pélvico por cada día extra en el tratamiento. • Niveles de hemoglobina. • Pacientes con Hb <12g/dl tienen menor respuesta a tratamiento. NCCN Guidelines Version 1.2016 Cervical Cancer The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Shang Wen Chen • • • • China. Retrospectivo. 1992-1997. 257 pacientes. Radiation and Oncology 67 (2003) 69-76 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Shang Wen Chen Radiation and Oncology 67 (2003) 69-76 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Shang Wen Chen Radiation and Oncology 67 (2003) 69-76 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Shang Wen Chen Radiation and Oncology 67 (2003) 69-76 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Shang Wen Chen Radiation and Oncology 67 (2003) 69-76 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Shang Wen Chen Radiation and Oncology 67 (2003) 69-76 The Effect of Hemoglobin Level on Radiotherapy Outcomes: The Canadian Experience Gillian Thomas • • • • Multicéntrico. Canadá. 630 pacientes. 1989-1992. Seminars in Oncology Vol 28 No 1 Suppl 8 2001; 60-65 The Effect of Hemoglobin Level on Radiotherapy Outcomes: The Canadian Experience Gillian Thomas Seminars in Oncology Vol 28 No 1 Suppl 8 2001; 60-65 The Effect of Hemoglobin Level on Radiotherapy Outcomes: The Canadian Experience Gillian Thomas Seminars in Oncology Vol 28 No 1 Suppl 8 2001; 60-65 Relationship Between Low Hemoglobin Levels and Outcomes After Treatment With Radiation or Chemoradiation in Patients with Cervical Cancer: Has the Impact of Anemia Been Overstated? Andrew J. Bishop • • • • • • 2454 pacientes. MDACC. 1980-2011. RT definitiva 43.2 – 45Gy. BQT 80-90Gy pto A. 702 pacientes (29%) QT concomitante. Int J Radiation Oncol Biol Phys Vol 91 No 1; 196-205, 2015 SLR Central SLMD SEE Conclusiones • El tiempo de protracción disminuye la supervivencia global y el control pélvico por cada día extra en duración de tratamiento (<8 semanas). • Los niveles de hemoglobina influyen en el control local y supervivencia enfermedad específica. ESTADIOS CLÍNICOS TEMPRANOS ESTADIOS CLÍNICOS TEMPRANOS • TRATAMIENTO DEFINITIVO • • • Pacientes médicamente inoperables o que rechazan cirugía. Radioterapia sola. Dosis 70-80Gy a punto A. NCCN Guidelines Version 1.2016 Cervical Cancer Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Fabio Landoni • • • • • • Aleatorizado, prospectivo. 1986 – 1991. 343 pacientes. EC Ib y IIa. Histerectomía radical tipo III Dosis Punto A 70-90Gy (mediana 76Gy). Lancet 1997; 350: 535-540 Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Fabio Landoni Lancet 1997; 350: 535-540 Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Fabio Landoni Lancet 1997; 350: 535-540 Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Fabio Landoni Lancet 1997; 350: 535-540 Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Fabio Landoni Lancet 1997; 350: 535-540 ESTADIOS CLÍNICOS TEMPRANOS • Beneficios de la cirugía sobre la radioterapia. • • • • • Menor tiempo de tratamiento. Preservación de la función ovárica. «Mejor función sexual». No hay riesgo de 2dos primarios. No hay toxicidad crónica. NCCN Guidelines Version 1.2016 Cervical Cancer TRATAMIENTO ADYUVANTE • Radioterapia (>1 riesgo intermedio). • • • Tumor >4cm. Invasión > 1/3 al estroma cervical. Permeación linfovascular. • Quimioradioterapia concomitante (riesgo alto). • • • Ganglios positivos. Márgenes positivos. Invasión a parametrios. Rotman MZ. Gynecol Oncol 1999; 177-183 Peters WA. J Clin Oncol 2000; 18: 1606-1613 Preservación de la función hormonal: •Transposición ovárica. • • • <45 años. Pre menopausia. Histología células escamosas. • Falla ovárica 5 - 10Gy. • Esterilidad 2 - 3Gy. J Pahisa. Int J Gynecol Cancer 2008, 18, 584-589 ENFERMEDAD AVANZADA IB2, IIA2, IIB-IVA ENFERMEDAD AVANZADA IB2, IIA2, IIB-IVA • TRATAMIENTO DEFINITIVO • • Quimioradioterapia concomitante. Dosis 70-80Gy a punto A NCCN Guidelines Version 1.2016 Cervical Cancer ENFERMEDAD AVANZADA IB2, IIA2, IIB-IVA National Cancer Institute: strong consideration should be given to the incorporation of concurrent cisplatin based chemotherapy with radiation therapy in women who require radiation therapy for treatment of cervical cancer. Gillian M Thomas. The New England Journal of Medicine 1999. ENFERMEDAD AVANZADA IB2, IIA2, IIB-IVA Riesgo relativo de muerte en pacientes tratados con QTRT y RT ESTUDIO Keys (GOG 123) FIGO n GRUPO CONTROL GRUPO EXPERIMENTAL RR DE MUERTE IB2 369 RT RT + CDDP 0.54 RT + CDDP semanal 0.61 RT + CDDP, 5FU, HU 0.58 Rose, Walkins (GOG 120) IIB-IVA 575 RT + HU Morris (RTOG 90-01) IB2-IVA 403 RT campo extendido RT + CDDP + 5FU 0.52 Whitney (GOG 85) IIB-IVA 388 RT + HU RT + CDDP + 5FU 0.72 Peters (SWOG 8797) IB o IIA 268 RT RT + CDDP + 5FU 0.50 Keys HM. N Engl J Med 1999; 340: 1154-1161 Rose PG. N Engl J Med 1999; 340: 1144-1153 Morris M. N Engl J Med 1999; 340: 1137-1143 Whitney CW. J Clin Oncol 1999; 1339-1348 Peters WA. J Clin Oncol 2000: 1606-1613 ENFERMEDAD AVANZADA IB2, IIA2, IIB-IVA Riesgo relativo de muerte en pacientes tratados con QTRT y RT Aumento de la supervivencia Supervivencia libre de enfermedad FIGO n Supervivencia global IB2 369 74% vs 83% 9% 63% vs 79% Rose, Walkins (GOG 120) IIB-IVA 575 47% vs 65% 18% 47% vs 67% Morris (RTOG 90-01) IB2-IVA 403 41% vs 67% 16% 40% vs 67% Whitney (GOG 85) IIB-IVA 388 43% vs 55% 12% 50% vs 60% Peters (SWOG 8797) IB o IIA 268 71% vs 81% 10% 63% vs 80% ESTUDIO Keys (GOG 123) Keys HM. N Engl J Med 1999; 340: 1154-1161 Rose PG. N Engl J Med 1999; 340: 1144-1153 Morris M. N Engl J Med 1999; 340: 1137-1143 Whitney CW. J Clin Oncol 1999; 1339-1348 Peters WA. J Clin Oncol 2000: 1606-1613 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale • 15 estudios aleatorizados. • 3452 pacientes. • RT vs QTRT J Clin Oncol 26: 5802-5812, 2008 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale J Clin Oncol 26: 5802-5812, 2008 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale J Clin Oncol 26: 5802-5812, 2008 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale J Clin Oncol 26: 5802-5812, 2008 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale J Clin Oncol 26: 5802-5812, 2008 RADIOTERAPIA A GANGLIOS PARA AÓRTICOS Prophylactic Irradiation of the Para Aortic Lymph Node Chain in Stage IIB and Bulky Stage IB Carcinoma of the Cervix, RTOG 7920 M. Rotman • • • • Cobalto 60. Dosis pelvis 4050Gy. Dosis para aórticos 45Gy. 367 pacientes. Int J Radiation Oncology Biol Phys Vol 19 513-521, 1990 Prophylactic Irradiation of the Para Aortic Lymph Node Chain in Stage IIB and Bulky Stage IB Carcinoma of the Cervix, RTOG 7920 M. Rotman Int J Radiation Oncology Biol Phys Vol 19 513-521, 1990 Prophylactic Irradiation of the Para Aortic Lymph Node Chain in Stage IIB and Bulky Stage IB Carcinoma of the Cervix, RTOG 7920 M. Rotman Int J Radiation Oncology Biol Phys Vol 19 513-521, 1990 Pelvic Irradiation with Concurrent Chemotherapy Versus Pelvic and Para Aortic Irradiation for High Risk Cervical Cancer: An Update of RTOG 90-01 Patricia Eifel • • • • 390 pacientes. Multicéntrico. Campos AP , PA, laterales opuestos. Dosis 45Gy (1.8Gy/fx). J Clin Oncol 22: 872-880, 2004 Pelvic Irradiation with Concurrent Chemotherapy Versus Pelvic and Para Aortic Irradiation for High Risk Cervical Cancer: An Update of RTOG 90-01 Patricia Eifel J Clin Oncol 22: 872-880, 2004 Pelvic Irradiation with Concurrent Chemotherapy Versus Pelvic and Para Aortic Irradiation for High Risk Cervical Cancer: An Update of RTOG 90-01 Patricia Eifel J Clin Oncol 22: 872-880, 2004 TÉCNICAS DE RADIOTERAPIA VOLÚMENES DE TRATAMIENTO • TRATAMIENTO DEFINITIVO • • • • • • • • • Enfermedad macroscópica. Parametrios. Ligamentos útero sacros. Margen vaginal (3cm). Ganglios pre sacros. Ganglios iliacos comunes, internos y externos. Ganglios obturadores. Ganglios para aórticos (nivel de los vasos renales): si hay ganglios positivos en iliaca común, para aórticos. Ganglios inguinales (invasión de tercio inferior de vagina). • RADIOTERAPIA POST OPERATORIA. • • • • • • 3-4 cm de cúpula vaginal. Parametrios. Ganglios pre sacros. Ganglios iliacos comunes, internos y externos. Ganglios obturadores. Ganglios para aórticos (nivel de los vasos renales): si hay ganglios positivos en iliaca común, para aórticos. NCCN Guidelines Version 1.2016 Cervical Cancer DOSIS RT EXTERNA • • • • Dosis: 40-50Gy en fracciones de 1.8-2Gy. Boost 10-15Gy a adenopatías voluminosas no resecables y parametrios. Braquiterapia: 30-40Gy a punto A (LDR). Dosis total punto A 80-85Gy. NCCN Guidelines Version 1.2016 Cervical Cancer IMRT for Advanced Cervical Cancer: a Comparison of Dosimetric and Clinical Outcomes with Conventional Radiotherapy Xue-lian Du • • • • 2005 a 2010. IIB – IIIB. 122 pacientes. 45-55Gy. Gynecologic Oncology 125 (2012) 151-157 IMRT for Advanced Cervical Cancer: a Comparison of Dosimetric and Clinical Outcomes with Conventional Radiotherapy Xue-lian Du Gynecologic Oncology 125 (2012) 151-157 IMRT for Advanced Cervical Cancer: a Comparison of Dosimetric and Clinical Outcomes with Conventional Radiotherapy Xue-lian Du Gynecologic Oncology 125 (2012) 151-157 IMRT for Advanced Cervical Cancer: a Comparison of Dosimetric and Clinical Outcomes with Conventional Radiotherapy Xue-lian Du Gynecologic Oncology 125 (2012) 151-157 BRAQUITERAPIA • Se usa braquiterapia intracavitaria. • Aplicador de cérvix: sonda central (tándem) + cápsulas laterales (ovoides o colpostatos). • Aplicador de vagina (cilindro). • Fuentes: • HDR: Ir192 • LDR: Cs137 American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 BRAQUITERAPIA: CLASIFICACIÓN DE ACUERDO A LA TASA DE DOSIS Tasa de dosis Valor de la tasa de dosis al sitio de prescripción Tasa baja de dosis (Low Dose Rate, LDR) 0.4-2 Gy/h Tasa media de dosis (Medium Dose Rate, MDR) 2-12 Gy/h Tasa alta de dosis (High Dose Rate, HDR) >12 Gy/h American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 BRAQUITERAPIA American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 APLICADORES DE FLETCHER SUIT DELCOS American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 BRAQUITERAPIA American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 BRAQUITERAPIA American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46 The Role of Intraoperative Radiation Therapy in the Management of Recurrent and Locally Advanced Gynecologic Cancers Olivia W. Foley Int J Gynecol Cancer 2013; 23: 9-15 The Role of Intraoperative Radiation Therapy in the Management of Recurrent and Locally Advanced Gynecologic Cancers Olivia W. Foley Int J Gynecol Cancer 2013; 23: 9-15 RECOMENDACIONES POST RT • Para evitar la estenosis vaginal y sequedad de la misma (2-4 semanas después del término de RT): • Relaciones sexuales. • Dilatador vaginal. • Humectantes/lubricantes vaginales.