Download Role of radiation therapy for local control of disease

Role of radiation therapy for
local control of disease
Nuran S Bese, MD
Professor of Radiation Oncology
Istanbul-Turkey
Role of radiation therapy for local
control of disease
• Requirements for Safe and Effective
Radiation Therapy
• Early Stage Breast Cancer (Stage I and II)
Whole-Breast Radiation Therapy (WBRT)
Post-mastectomy Radiation Therapy (PMRT)
• Locally Advanced Breast Cancer (LABC)
Requirements for Safe and Effective
Radiation Therapy for Breast Cancer
Bese et al, Breast J. 2006 Jan-Feb;12 Suppl 1:S96-102
WHO Recommendations
• 1 Radiation Oncologist /250 new cancer patients
•
1 Megavoltage equipment / 300 new patients
•
5 Megavoltage equipment / 1 million population
• Actual supply of megavoltage equipment is only 18%
of the estimated need.
Barton et al. Lancet Oncol. 2006;7:584-595.
Cobalt-60
Linear accelerator
Advantages
Disadvantages
Advantages
Disadvantages
-Cheaper
-More simple
mechanical,
electrical
components and
operations
-Easy to maintain
-Relative
constancy of
beam out-put,
predictability of
decay
-QA program is
simple
-Poor field flatness
-Lower % depth
dose
-Greater penumbra
-Lower dose rate
-Less favorable
beam out-put
-Need of changing
source every 5
years
-Inability to deliver
complex
treatments
-Ability of
delivering
complex
treatments
-Better dose
distribution
especially
after BCS
-Decreased
skin dose
especially
after BCS
-Decreased
dose to the
contralateral
breast
-Preventive
maintenance is
essential,
expensive and
requires a
maintenance
technician
- More detailed
QA program is
needed
Other Requirements
• Maintenance of the equipments
• Education of the staff and patients
• Logistic issues, geographic accessibility,
support systems
• Social security for health
• Requirements for Safe and Effective
Radiation Therapy
• Early Stage Breast Cancer (Stage I and II)
Whole-Breast Radiation Therapy (WBRT)
Post-mastectomy Radiation Therapy (PMRT)
• Locally Advanced Breast Cancer (LABC)
Early Stage Breast Cancer (Stage I and II)
Whole-Breast Radiation Therapy (WBRT)
Conservation Surgery
+ RT
Mastectomy
Trial
No. of
Pts.*
Tumor
Size
(cm)
Tumor
Control
(%)
DiseaseFree
survival (%)
Tumor
Control
(%)
DiseaseFree
Survival (%)
Guy’s
182/188
<4
T1, 80
T2, 30
80
T1, 90
T2, 80
80
60
Milan
351/349
2
92
60 (20 y)
98
60 (20 y)
NSABP
515/494
4
85
37 (20 y)
93
37 (20 y)
NCI
121/116
5
88
63 (18 y)
90
67 (18 y)
EORTC, 2000
466/436
5
80
60.5
88
66 (18 y)
DBCG
430/429
5
97
70
96
66
G. Roussy
88/91
2
87
55
82
45 (15 y)
*Number receiving conservation therapy plus RT/No. receiving
mastectomy.
BCS+RT / BCS Prospective Randomized Trials
Study
Local
Overall Survival
Recurrences(%)
(%)
BCS
BCS+RT BCS
BCS+RT
Followup
(year)
NSABP
39
14
46
46
20
Milan III
23
6
77
82
10
Scotch
24
6
85
88
5
Sweden
24
8.5
78
78
10
Ontario
40
18
72
74
10
England
35
13
-
-
5
Early Breast Trialists Coll Group Lancet 366:2087, 2005
BCS: Impact of Radiation Therapy on
Long-term Survival
Early Breast Cancer Trialists’ Collaborative Group: Lancet 355:1757, 2000
BCS: Impact of Radiation Therapy on
Long-term Survival
Early Breast Cancer Trialists’ Collaborative Group: Lancet 355:1757, 2000
Tangential breast field
CONCLUSION: WBRT
• Women deserves RT after BCS
• Tamoxifen seems appropriate in older
patients ( aged≥ 70) with ER+ cancers,
particularly if serious co morbidities
are present
WBI± RLI: 46-50Gy over 5-6 weeks with 1.8-2Gy
fractions
EORTC BOOST TRIAL:
10 year-LC
Bartelink et al, JCO 2007;25;3259
EORTC BOOST TRIAL
• Central pathological review of 1616 patients
• Boost reduced LR (HR=0.47)
• Boost reduced LC for patients < 50years (HR=0.51)
and for patients with G3 tumors (HR=0.42)
• Boost is effective for younger or high grade tumors
• No boost seems reasonable for older patients with
grade 1,2 tumors
Jones et al. JCO 2009;27:4939
Hypofractionated Schedules
140-month results of Canadian Accelerated
WBRT
Whelan T; J N Cancer Inst. 2002;94:1143 SABCS 2007 Abstract
Alternative for women over 60 with G1,2 tumors.
Resource sparing strategy
Maximum attention for cardio toxicity !
APBI
• Uncertainty about long term results; large fractionsvolumes
• Learning curve is inevitable
• Still investigational
• Requirements for Safe and Effective
Radiation Therapy
• Early Stage Breast Cancer (Stage I and II)
Whole-Breast Radiation Therapy (WBRT)
Post-mastectomy Radiation Therapy (PMRT)
• Locally Advanced Breast Cancer (LABC)
PMRT: Randomized Trials DBCS 82-B/82-C
• Number of dissected
lymph nodes
• CMF
• Duration of Tamoxifen
Overgaard M et al
Radiother & Oncol 82: 247, 2007
PMRT: Randomized Trials British Columbia
Locoregional recurrence free survival (all)
overall survival (all)
Ragaz et al.J Natl Cancer Inst 97,116-26, 2005
g
Sir Richard Peto, San Antonio, dec 2006
EBCTCG
PMRT for N0
• Should post mastectomy radiation therapy
be systematic for pT2-pT3N0 breast cancer?
• T2+
• Grade 2-3
• HR• LVI
• Premenopausal
• Close surgical margin <2mm
• No systemic treatment
PMRT: RT FIELDS
• Patients with ≥ 4 lymph nodes: chest-wall +scf
• Patients with<4 lymph nodes: chest-wall ± scf
• Routine axillary irradiation
(low axillary recurrence and the risk of arm
oedema)
inadequate axillary dissection
patients with more than 10 involved lymph nodes
Chang etal. IJROBP 2007 ;67:1043-51
Internal Mammary Chain RT
• IMC RT is recommended
for patients with clinically
or pathologically positive
internal mammary lymph
nodes with the use of 3-D
treatment planning.
• IMC RT is considered if the
primary tumor is located at
the inner quadrant with
other adverse risk factors
•
• Requirements for Safe and Effective
Radiation Therapy
• Early Stage Breast Cancer (Stage I and II)
Whole-Breast Radiation Therapy (WBRT)
Post-mastectomy Radiation Therapy (PMRT)
• Locally Advanced Breast Cancer (LABC)
Locally Advanced Breast Cancer
•
In low resource countries, 30-60% of patients present with
LABC
• Initial treatment is systemic therapy
• No survival advantage of neoadjuvant CT
• Inoperable tumors can become operable
• Endocrine therapy is an alternative for HR+
• After response to CT: Mastectomy
• Selected patients with non-inflammatory disease: BCS
• Post-op RT is an essential component for LC
• Inoperable tumors after cross resistant CT, pre-op RT 45-50Gy
• CT→cross-resistant CT→in-op→RT45Gy→definitive RT
LABC
Local-regional recurrence for patients treated
with RT ( 542 patients) and without RT (134 patients,)
Huang, E. H. et al. J Clin Oncol; 22:4691-4699 2004
LABC: NEOADJUVANT CT
LRR initial clinical stage III or IV tumors,
subsequently achieved a path complete response
Huang, E. H. et al. J Clin Oncol; 22:4691-4699 2004
• RT is the essential component of local
treatment of Early and LABC
• RT is an efficient tool for the palliation of
metastatic disease