Meer sparend bestraling van de axilla? Less is more (than enough) Nicola Russell

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1 Meer sparend bestraling van de axilla? Less is more (than enough) Nicola Russell

2 Techniek tot nu toe Conventionele simulatie Virtuele simulatie

3 Techniek voor okselbestraling Klier levels I III Plexus brachialis

4 Planning

5 Acute bijwerking: huid epidermolyse periclaviculair

6 Sub-acute bijwerking: stralingspneumonitis In periclav veld <1% kans bij mamma RT alleen 4-5% kans bij mamma + oksel RT

7 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: 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: without axillary surgery patients with limited axillary dissection Moderate severe Arm oedema in 1.2% (5 patients) persistent in 4 patients

8 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: 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: without axillary surgery patients with limited axillary dissection 1.2% transient brachial plexopathy (resolved without treatment)

9 Zeer late bijwerking: schoudergordel spieratrofie RT oksel en periclaviculair rechts in 1989, links in 2004 (Foto 2010)

10 Spier en bot in okselveld Plexus brachialis humeruskop scapula

11 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: 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: without axillary surgery patients with liited axillary dissection 1.4% (6 patients) axillary recurrence, 4 with simultaneous distant metastases

12 Doelgebied? Is het nodig om de gehele oksel en periclaviculaire kliergebied te bestralen bij SN+ tumoren?

13 Aantal axillaire klieren in AMAROS trial ALND arm (n=300) Median age RT arm (n=266) Menopausal status pre 88 (29.3) 93 (35.0) peri 19 (6.3) 20 (7.5) post 176 (58.7) 142 (53.4) pt stage <= 1 cm 30 (10.0) 33 (12.4) 1< 2 cm 162 (54.0) 141 (53.0) SNB results 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 micro 182 (60.7) 78 (26.0) ITC 32 (11) pn stage 1 3 nodes 261 (87.0) NA 4 9 nodes 25 (8.3) NA 10+ nodes 12 (4.0) NA 175 (65.8) 59 (22.2) 31 (12) Histology ductal 216 (72.0) 198 (74.4) lobular 39 (13.0) 31 (11.7) Others 45 (15.0) 37 (13.9) Grade I 66 (22.0) 64 (24.1) II 141 (47.0) 120 (45.1) III 85 (28.3) 77 (28.9) Surgery BCT 260 (86.7) 238 (89.4) MST 37 (12.3) 28 (10.5)

14 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 + nslnmetastasespage.aspx

15 Kans op verdere klieren in de oksel bij SN+

16 Voorstel Voor laag risico ziekte alleen bestraling van de chirurgische oksel (levels I en II)

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32 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!