Transcript Radiotherapie na neoadjuvante therapie

Radiotherapy after neo-adjuvant
chemotherapy
Lustrumcongres “Moeilijke Mamma’s”
31 januari 2014
dr Paula Elkhuizen
Radiotherapeut-oncoloog
Indications for neoadjuvant
chemotherapy (NAC)
- Patients with inflammatory breast cancer
- Patients who might become eligible for BCT after NAC
- Patients treated in trials investigating the effect of NAC
Before start
neo-adjuvant chemotherapy;
consult radiotherapy
Pre-NAC consult; locally advanced;
in all cases RT indication
Infra/supraclaviculair;
RT doses
Huid betrokkenheid;
RT opheffen huidsparing; bolus
Uitbreiding huidlaesies;
Aanpassing RT veld
Radiotherapy after neo-adjuvant
chemotherapy
• RT indication
– (Patient factors)
– Pathological T stage
– pathological N stage
– Histological factors (lymfangio-invasion, grade etc)
Which patients need RT ??
After neo-adj CT (partly) unknown…..
Indications for post-operative radiotherapy
after neoadjuvant chemotherapy
First serie 2002, IJRBOP Buchholz et al: MD Anderson
2 prospective trials (neo) adj CT and mastectomy
150 pts NAC and surgery –
NO RT based on ypTNM
5 yr LRR
27%
5 yr LRR
15%
compared to
1031 pts surgery and adjuvant chemotherapy –
NO RT based on pTNM
p = 0.001
2002, IJRBOP Buchholz et al: MD Anderson
• For all path T size;
–LRR NEO was higher than LRR ADJ
• All cT3-T4 patients but
1, experienced
a LRR
Not
only ypTNM
but also cTNM stage
•> 4 nodes involved;
toNEO
chemotherapy
is important!!
– higherprior
LRR in
group (54% vs 23%)
• Subgroup (y)pT2N1-3 nodes positive:
– Higher LRR in NEO group 32% vs 8% in ADJ group
McGuire et al IJROBP 2007, n= 106
Patients with pCR after NAC and surgery
Retrospective serie, RT (n= 72) and no RT (n=34)
• Clinical Stage I-II;
– RT no influence (10 yrs LRR 0%)
• Clin Stage III (T1-3N2-3)
– RT improves LRR 7.3% vs 33.3 %
– RT improves DFS and OS
Radiotherapy after NAC
• Indications RT:
– cT3-4; cN2-3
– ypT3-4; ypN2-3
• Problem: intermediate groep
– cT1-2N1
– ypT1-2 N0-1
Also in case of
complete response!!
Radiotherapy after NAC
-intermediate group-
• scarse literature NAC and LRR
– Conflicting results
• Most databases
– no NAC in case of operable breast carcinoma
• More recent NAC series;
– role of RT in case of N+ was known; (LR and OS)
– RT according to physician
• NSABP rule untill late 90’s:
– no regional lymphnode RT, no PMRT
N= 3088
Neo-adjuvant chemotherapy trials
All patients NO radiotherapy
>10 yrs Follow up
cT1-3N0-1
Manoumas et al.
• NSABP B-18;
– n= 1523 ;
• NSABP-27;
– n= 2411;
1e prospective serie
N=3088 pt
1988-1993;
med FU 15.4 yrs
1995-2000;
med FU 11.75 yrs
• Neo-adjuvant chemotherapy
• Disadvantage; cN clinically without ultrasound + cytology
Manoumas et al. 1e prospective serie
N=3088 pt
• 10 yrs LRR after mastectomy 12.3%,
• 10 yrs LRR after BCT
10.3 %
Risk factors for LRR
• BCT:
• mastectomy:
– age not sign
age and cN; ypT and ypN
cT and cN; ypT and ypN
cT <= 5 cm
10 yrs LRR after
Mastectomy- no RT
Most LRR
in case of ypN+;
especially when cN+
Especially when T3
cT > 5cm
>= 50 yrs
10 yrs LRR after BCT
with RT breast
Most LRR
in case of ypN+;
especially when cN+
and Age <50 yrs
< 50 yrs
In the mean time: Rapchem
RAdiotherapy after Primary CHEMo therapy
• Onduidelijkheid; veel onder- en overbehandeling
• Gerandomiseerde trial niet mogelijk binnen NL
• Registratie studie met behandel richtlijn;
– Uniformiteit binnen NL
– Registreren van gegevens
RAPCHEM (treatment guidelines)
according to ypN status
•
Group I: ypT1-2N0:
LR risk < 10%
» after MRM: no RT.
•
Group II: ypT1-2N1:
LRR risk 10-35%
» after MRM: RT thoracic wall.
•
Group III: ypT1-2N≥2:
high LRR risk
» after MRM: RT thoracic wall and supraclavicular nodes.
(RT axilla and IMS optional)
Rapchem
Patients with cT1-2cN1
All radiotherapy institutes conform to these guidelines
Started January 2011
N= 720
Rapchem
Patients with cT1-2cN1
N1 status
- cytologie/histologie
- positieve SN
Indien > 3 pathologische klieren axillair op echo/ MRI/ PET
 cN2 (4+); RT indicatie ongeacht respons
Indien N1: ook echo periclav pre-chemo: klieren infra/supraclav +
 cN3;
RT indicatie ongeacht respons
Pre-NAC consult; cT1-2N0-1
N1: Echo periclav?
N+; aantal klieren ivm
RAPCHEM;
indien >= 3 klieren; cN2(4+);
RT indicatie ongeacht
respons
Kans post-operatieve RT;
evt reconstructie
RAPCHEM (treatment guidelines)
according to ypN status
•
Group I: ypT1-2N0:
T2N0 met graad III of LVI
T3N0
» after MRM: no RT.
•
Group II: ypT1-2N1:
Neo Supremo
no RT vs thoracic wall RT
» after MRM: RT thoracic wall.
•
Group III: ypT1-2N≥2:
» after MRM: RT thoracic wall and supraclavicular nodes.
(RT axilla and IMS optional)
Low
intermediate
high
/ 19
Low-intermediate risk pts are upstaged to cN2(4+) and N3 (22%)
ypN0;
indication RT missed
(9%)
ypN1;
regional lymph node area missed
(6%)
ypN2-3;
RT given (PET upstage no influence)
(7%)
High Risk patients
RT field adaption in 15 %
Radiotherapy after neo-adjuvant
chemotherapy- conclusions
• Classical factors (cT, cN, grade, LVI)
– after NAC (partly) unknown
Before start
• RT indication cT3-4; cN2-3
• RT indication ypT3-4; ypN2-3
neo-adjuvant chemotherapy;
• also in case of pCR
consult
radiotherapy
RAPCHEM
• Intermediate group (cT1-2N1; ypT1-2 N0-1)
–
• PET scan; changes local treatment in 15% of the pts
RAPCHEM
RAdiotherapy after Primary CHEMo therapy
Writing committee
•
Radiotherapie:
– LJ Boersma, PHM Elkhuizen, P Poortmans
•
Chirurgie
– T van Dalen
•
Medische oncologie
– S Linn
•
Pathologie
– J Wesseling
•
Statistiek/methodologie
– A Voogd, R Houben
5 years LRR
according to
(y)pN stage
Matched group
1 NEO with 2 ADJ
No differences in age, ER, PR