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!
