GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER...
-
Upload
kory-barton -
Category
Documents
-
view
220 -
download
2
Transcript of GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER...
![Page 1: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/1.jpg)
GÜNTHER GRUBER
Institut für Radio-Onkologie
guenther.gruber @ ksa.ch
RADIOTHERAPY RADIOTHERAPY IN BREAST CANCERIN BREAST CANCER
(PART 1: CONSERVATION)(PART 1: CONSERVATION)
![Page 2: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/2.jpg)
AIMS OF RTAIMS OF RT
• Breast conservation
• Local control
• Overall survival
• Reduction of side effects
![Page 3: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/3.jpg)
TOPICSTOPICS
• Breast conserving therapy (BCT)
• RT after mastectomy
• Complications
• New trends
![Page 4: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/4.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
NON-INVASIVE CANCERNON-INVASIVE CANCER
RT in LCIS ?RT in LCIS ?
![Page 5: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/5.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
NON-INVASIVE CANCERNON-INVASIVE CANCER
RT in LCIS ?RT in LCIS ?
No solid dataNo solid data
multicentricity (-88%)multicentricity (-88%)contralateral pos. biopsies (-59%)contralateral pos. biopsies (-59%)
10-35% progression to invasive cancer10-35% progression to invasive cancerafter 20 – 25 years follow-upafter 20 – 25 years follow-up
![Page 6: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/6.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
NON-INVASIVE CANCERNON-INVASIVE CANCER
RT in DCIS ?RT in DCIS ?
![Page 7: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/7.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
NON-INVASIVE CANCERNON-INVASIVE CANCER
RT in DCIS ?RT in DCIS ?
Omission of RT ?Omission of RT ?
![Page 8: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/8.jpg)
Omission of RT after Omission of RT after breast conserving surgery for DCISbreast conserving surgery for DCIS
0
10
20
30
40
50
60
70
Los Angeles Detroit
low risk = G1, up to 2cmG2, up to 1cm
high risk => 2cm or G3
SEER data; Katz et al.; J Clin Oncol, 2005
Diagnosis2002
BREAST CONSERVATIONBREAST CONSERVATION
DCISDCIS
![Page 9: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/9.jpg)
VAN NUYS PROGNOSTIC INDEXVAN NUYS PROGNOSTIC INDEX
BREAST CONSERVATIONBREAST CONSERVATION
DCISDCIS
SIZE -15mm 116-40mm 2>40mm 3
G low w/o necrosis 1low with necrosis 2high 3
RR 10+mm 11-9mm 2<1mm 3
New: AGE >60yrs 140 – 60yrs 2<40yrs 3
![Page 10: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/10.jpg)
LOCAL CONTROL: Multivariate analysisLOCAL CONTROL: Multivariate analysisSilverstein, 2002
G Age Size RR
BREAST CONSERVATIONBREAST CONSERVATION
DCISDCIS
Van Nuys series
![Page 11: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/11.jpg)
Prospective study for omission of RTProspective study for omission of RTin ‚good risk‘ (mammo-2.5cm; G1/2; RR 10+mm)in ‚good risk‘ (mammo-2.5cm; G1/2; RR 10+mm)
BREAST CONSERVATIONBREAST CONSERVATION
DCISDCIS
J Wong et al., J Clin Oncol 2006
12 % LR at 5 years !
Stopped early with 158 pts (/200)
![Page 12: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/12.jpg)
Omission of RT in ‚good risk‘ Omission of RT in ‚good risk‘
BREAST CONSERVATIONBREAST CONSERVATION
DCISDCIS
tamoxifenRTOG 9804
tamoxifen + RT
![Page 13: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/13.jpg)
LOCAL CONTROL: Multivariate analysisLOCAL CONTROL: Multivariate analysisSilverstein, 2002
G Age Size RR
BREAST CONSERVATIONBREAST CONSERVATION
DCISDCIS
Van Nuys series
RT
![Page 14: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/14.jpg)
Randomised studies in DCIS with or Randomised studies in DCIS with or without radiotherapywithout radiotherapy
Local control – Efficacy of RTLocal control – Efficacy of RT
Trial n f-up Op Op+RT HR p
NSABP B17 818 5yr 16% 7% 0.43 <0.001
EORTC 10853 1010 10yr 26% 15% 0.53 <0.0001
UKCCCR 1701 5yr 14% 6% 0.38 <0.001
Risk reduction in all subgroups (to various degrees)RT with 50Gy
=> As expected: no difference in overall survival!
![Page 15: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/15.jpg)
Randomised studies in DCIS with or Randomised studies in DCIS with or without radiotherapywithout radiotherapy
Local control – Efficacy of RTLocal control – Efficacy of RT
![Page 16: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/16.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
DCIS – Impact of boost?DCIS – Impact of boost?
![Page 17: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/17.jpg)
median 50 Gy (±1)
median 60 Gy (±1)
Omlin et al. Lancet Oncol, 2006
median: 60Gy (±1)
median: 50Gy (±1)
keine RT
DCIS – Impact of boost?DCIS – Impact of boost?
BREAST CONSERVATIONBREAST CONSERVATION
…in young women (-45 years)
![Page 18: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/18.jpg)
Gruber et al., unpublished
DCIS – Impact of boost?DCIS – Impact of boost?
BREAST CONSERVATIONBREAST CONSERVATION
…in young women (-45 years)
median: 60Gy (±1)
median: 50Gy (±1)
no RT
Mastectomy
![Page 19: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/19.jpg)
For which pts. with For which pts. with DCIS DCIS radiotherapy canradiotherapy canbe omitted after breast conserving surgery?be omitted after breast conserving surgery?
Evidence-based medicine (3 published studies + 1 as abstract):NO OMISSION OF RT!
Probably yes: clinging or micropapillary growth?; RR ≥ 10mm?(CAVE: young patients! VAN NUYS: >=10mm; <40yrs: n=15!)
Interdisciplinarity is very important !
BREAST CONSERVATIONBREAST CONSERVATION
![Page 20: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/20.jpg)
INVASIVE CANCERINVASIVE CANCER
• BCT vs mastectomy ?
BREAST CONSERVATIONBREAST CONSERVATION
![Page 21: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/21.jpg)
23.3 23.8
41.7 41.2
0
5
10
15
20
25
30
35
40
45
distant meta overall survival
BCT
Mastectomy
Milan I Trial (Mastectomy vs BCT)20 yrs – Results%
Veronesi et al., NEJM 2002 p=0.8 p=1.0
BREAST CONSERVATIONBREAST CONSERVATION
![Page 22: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/22.jpg)
NSABP-06 Trial (Mastectomy vs BCT)20 yrs – Results
5451
54 53
0
10
20
30
40
50
60
distant meta overall survival
BCT
Mastectomy
%
Fisher et al., NEJM 2002 p=0.95 p=0.74
BREAST CONSERVATIONBREAST CONSERVATION
![Page 23: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/23.jpg)
CONCLUSIONCONCLUSION
• BCT + Mastectomy equivalent !
BREAST CONSERVATIONBREAST CONSERVATION
![Page 24: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/24.jpg)
INVASIVE CANCERINVASIVE CANCER
• BCT vs mastectomy ?• Breast conserving surgery: Omission of RT ?
BREAST CONSERVATIONBREAST CONSERVATION
![Page 25: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/25.jpg)
Studies MedianFollow-up
Op LRw/o RT
LRwith RT
NSABP B-06 125 months Lump-ectomy
35% 9%
Scottish Cancer Trial
68 months Lump-ectomy
24% 6%
Uppsala-Örebro Study Group
106 months Segment-ectomy
22% 7%
Ontario Cancer Inst.
91 months Lump-ectomy
35% 11%
Milano III 109 months Quadrant-ectomy
22% 5%
Local relapse: BC surgery +/- RT
BREAST CONSERVATIONBREAST CONSERVATION
![Page 26: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/26.jpg)
10
29.2
17.420.3
13.1
46.5
36.5
45.2
0
510
1520
2530
3540
4550
10yr-LR 10yr-CSS 10yr-LR 10yr-CSS
with RT
w/o RT
EBCTCG 2000 RT metaanalysis, Lancet 12/05
%
p<0.00001 p=0.006 p<0.00001 p<0.01
N0 N+/N?n=6097 n=1214
BREAST CONSERVATIONBREAST CONSERVATION
![Page 27: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/27.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
![Page 28: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/28.jpg)
CONCLUSIONCONCLUSION
• BCT + Mastectomy equivalent !• BC surgery: No omission of RT !
BREAST CONSERVATIONBREAST CONSERVATION
![Page 29: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/29.jpg)
INVASIVE CANCERINVASIVE CANCER
• BCT vs mastectomy ?• Breast conserving surgery: Omission of RT ?• Omission of RT in ‚low risk‘ ?
BREAST CONSERVATIONBREAST CONSERVATION
![Page 30: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/30.jpg)
BC surgery +/- RTBC surgery +/- RTSwedish Breast Cancer Group, EJC 2003
median tu-size: 12mm; n=1187;median F-up: 8J
14%
4%
BREAST CONSERVATIONBREAST CONSERVATION
![Page 31: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/31.jpg)
p=0.01
16.5
9.3
2.8
p<0.0001
NSABP B-21, n=1009; JCO 2002
BC surgery +/- RT, pT1a/pT1b pN0
BREAST CONSERVATIONBREAST CONSERVATION
![Page 32: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/32.jpg)
Local relapse rates, pT1a/pT1b pN0
Age 70+ ?
Therapy,-ies n LR
TAM 43 3 (7%)RT 59 5 (8%)TAM+RT 57 0
RT vs. TAM => HR 1.06 (0.25-4.46) !NSABP B-21, n=1009 JCO, 2002
BREAST CONSERVATIONBREAST CONSERVATION
![Page 33: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/33.jpg)
CALGB, RTOG, ECOG (Hughes et al. NEJM, 9/2004)
n=636 (75+ years: 55%)median F-up: 5J
… in T1, N0, R0, ER+ (in 97%), >70yrs
LOCAL RELAPSE
with tamoxifen 4%with tamoxifen and RT 1%
p<0.001
BREAST CONSERVATIONBREAST CONSERVATION
![Page 34: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/34.jpg)
T1/T2, >50yrs: 769 randomised (of 1572 ‚eligible‘ pts.)
5yrs LR
-2cm, R0, HR+ n=611
Tam 3.2%Tam + WB-RT 0.4% (p<0.001)
-1cm, R0, HR+ n=263
Tam 2.6%Tam + WB-RT 0% (p=0.02)
Files et al., NEJM 2004
BREAST CONSERVATIONBREAST CONSERVATION
![Page 35: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/35.jpg)
T1/T2, >50yrs: 769 randomised (of 1572 ‚eligible‘ pts.)
5yrs LR 8yrs LR
-2cm, R0, HR+ n=611
Tam 3.2% 15.2% Tam + WB-RT 0.4% (p<0.001) 3.6%
-1cm, R0, HR+ n=263
Tam 2.6%Tam + WB-RT 0% (p=0.02)
+ 3J
x 5 !
Files et al., NEJM 2004
BREAST CONSERVATIONBREAST CONSERVATION
![Page 36: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/36.jpg)
T1/T2, >50yrs: 769 randomised (of 1572 ‚eligible‘ pts.)
5yrs LR 8yrs LR
-2cm, R0, HR+ n=611 (B21)
Tam 3.2% 15.2% (16.5%) Tam + WB-RT 0.4% (p<0.001) 3.6% ( 2.8%)
-1cm, R0, HR+ n=263
Tam 2.6%Tam + WB-RT 0% (p=0.02)
+ 3J
x 5 !
Files et al., NEJM 2004
BREAST CONSERVATIONBREAST CONSERVATION
![Page 37: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/37.jpg)
ABCSG 8 (8A) (Pötter et al. ASTRO, OEGRO, ECCO 13, 11/2005)
n=826 (60+ years: about two thirds)median F-up: 42 mo
postmenop., T <3cm, N0, ER+ and/or PR+
LOCAL RELAPSE 5yrs
with Tamoxifen/AI 4.5%with Tamoxifen/AI and RT 0.6%
p=0.001
BREAST CONSERVATIONBREAST CONSERVATION
![Page 38: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/38.jpg)
„„low risk“ – studieslow risk“ – studiessummary
Follow up still too short !No subgroup of pts. which does not profit from RT!
IMPORTANT: Trade-offs !
If overall survival > 5yrs: RT !
BREAST CONSERVATIONBREAST CONSERVATION
![Page 39: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/39.jpg)
CONCLUSIONCONCLUSION
• BCT + Mastectomy equivalent !• BC surgery: No omission of RT !• No omission of RT in ‚low risk‘ !
BREAST CONSERVATIONBREAST CONSERVATION
![Page 40: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/40.jpg)
INVASIVE CANCERINVASIVE CANCER
• BCT vs mastectomy ?• Breast conserving surgery: Omission of RT ?• Omission of RT in ‚low risk‘ ?• PBI for ‚low risk‘ ?
BREAST CONSERVATIONBREAST CONSERVATION
![Page 41: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/41.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
![Page 42: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/42.jpg)
RATIONALE for PBI
small RT volume offers the possibility for highersingle doses=> Shorter treatment time (4-5 days vs 5 weeks)
Socio-economic aspects
small RT volume has likely less long-termcomplications
RT of whole breast necessary ?
BREAST CONSERVATIONBREAST CONSERVATION
![Page 43: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/43.jpg)
‚ Never change a winning team ! ‘(whole breast irradiation)
Less experience !
Target volume ?
Residual tumor cells ?
Patient selection ?
BREAST CONSERVATIONBREAST CONSERVATION
PROBLEMS for PBI
![Page 44: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/44.jpg)
Local relapse out of ‚tu bearing quadrant‘
TRIALTRIAL f-up f-up OPOP OP+RT OP+RT
NSABP-B06 125 2.7% 3.8%MAILAND 39 1.5% 0%UPPSALA 64 3.5%ONTARIO 43 3.5% 1.0%
Modified after Baglan et al., 2001
RANDOMISED STUDIESRANDOMISED STUDIES
BREAST CONSERVATIONBREAST CONSERVATION
![Page 45: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/45.jpg)
Intraoperative Radiotherapy
in Phase III
BREAST CONSERVATIONBREAST CONSERVATION
in Phase III
![Page 46: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/46.jpg)
Interstitial Brachytherapy (iBT)
Most data in the literature are based on iBT !
in Phase III
BREAST CONSERVATIONBREAST CONSERVATION
![Page 47: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/47.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
![Page 48: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/48.jpg)
![Page 49: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/49.jpg)
Brachytherapy-Ballon (Mammosite ®)
In USA very frequent !
in Phase III
BREAST CONSERVATIONBREAST CONSERVATION
![Page 50: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/50.jpg)
Brachytherapy-Ballon (Mammosite ®)
BREAST CONSERVATIONBREAST CONSERVATION
Registry Trial; n=1449; Median f-up: 14 mo
2yrs local failure: 1.2% (isolated LF 0.8%)
2yrs axillary failure: 1.0% (isolated AF 0.6%)
Good/excellent cosmesis6mo 12mo 18mo 24mo 36mo95.1% 93.7% 91.3% 93.5% 90.4%
Vicini F et al. ASCO; 2006
![Page 51: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/51.jpg)
3D (IMRT; protons) percutaneous RT
Few data !
in Phase III
BREAST CONSERVATIONBREAST CONSERVATION
![Page 52: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/52.jpg)
PBI only
William Beaumont HospitalWilliam Beaumont Hospitaln=199 (92% pT1), f-up: 65mon=199 (92% pT1), f-up: 65moHDR: 32 Gy / 8fx / 4dHDR: 32 Gy / 8fx / 4dLDR: 50 Gy, 0.52Gy/h, 96hLDR: 50 Gy, 0.52Gy/h, 96h
actuarial LR (5J)actuarial LR (5J)WB-RT: 1% PBI: 1%
PBI as good as WB-RT !
Vicini et al., 2003
BREAST CONSERVATIONBREAST CONSERVATION
![Page 53: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/53.jpg)
Manchester Trial (Phase III); 1982-87; n = 708;
Breast + LN (4MV;40Gy/15fx)Randomisation
PBI (10MeV; 40-42.5Gy/8fx)• no axillary diss.• no systemic therapy• no microscopic resection margin determination• in 42% no Tumor size determination
11%LOCAL REL.
20%
PBI only
BREAST CONSERVATIONBREAST CONSERVATION
![Page 54: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/54.jpg)
„„low risk“ – PBI?low risk“ – PBI?Summary
(So far) no standard !Phase III studies ongoing !Anyway, only for ‚low risk‘ !Expertise ?
BREAST CONSERVATIONBREAST CONSERVATION
![Page 55: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/55.jpg)
CONCLUSIONCONCLUSION
• BCT + Mastectomy equivalent !• BC surgery: No omission of RT !• No omission of RT in ‚low risk‘ !• The target is the whole breast !
BREAST CONSERVATIONBREAST CONSERVATION
![Page 56: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/56.jpg)
INVASIVE CANCERINVASIVE CANCER
• BCT vs mastectomy ?• Breast conserving surgery: Omission of RT ?• Omission of RT in ‚low risk‘ ?• PBI for ‚low risk‘ ?• Altered fractionation?
BREAST CONSERVATIONBREAST CONSERVATION
![Page 57: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/57.jpg)
altered fractionationaltered fractionation
Whelan et al., JNCI 94, 2002
Stage I/IIn=1234
median f-up : 69 months
R
42.5Gy/2.65Gy22 daysn=622
50Gy/2Gy35 daysn=612
BREAST CONSERVATIONBREAST CONSERVATION
![Page 58: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/58.jpg)
Whelan et al., JNCI 94, 2002
LRFS DFS
100%
95%
altered fractionationaltered fractionation
BREAST CONSERVATIONBREAST CONSERVATION
![Page 59: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/59.jpg)
altered fractionationaltered fractionation
Owen et al., Lancet Oncol, 2006
T1-3 N0-1n=1410
median f-up : 9.7 years
R
42.9Gy/3.3Gy5 wksn=466
50Gy/2Gy5 wksn=470
BREAST CONSERVATIONBREAST CONSERVATION
39Gy/3Gy5 wksn=474
![Page 60: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/60.jpg)
altered fractionationaltered fractionation
BREAST CONSERVATIONBREAST CONSERVATION
Owen et al., Lancet Oncol, 2006
![Page 61: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/61.jpg)
HR LR 5yrs 10yrs
altered fractionationaltered fractionation
BREAST CONSERVATIONBREAST CONSERVATION
Owen et al., Lancet Oncol, 2006
50Gy 1 7.9% 12.1%
42.9Gy 0.86 7.1% 9.6%
39Gy 1.33 9.1% 14.8%
=> alpha/beta is 4 (95%CI 1-7.8); 41.6Gy/3.2Gy = 50Gy/2Gy!
![Page 62: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/62.jpg)
CONCLUSIONCONCLUSION
• BCT + Mastectomy equivalent !• BC surgery: No omission of RT !• No omission of RT in ‚low risk‘ !• The target is the whole breast !• There are equivalent schedules !
BREAST CONSERVATIONBREAST CONSERVATION
![Page 63: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/63.jpg)
INVASIVE CANCERINVASIVE CANCER
• BCT vs mastectomy ?• Breast conserving surgery: Omission of RT ?• Omission of RT in ‚low risk‘ ?• PBI for ‚low risk‘ ?• Altered fractionation?• Increase of dose (boost) ?
BREAST CONSERVATIONBREAST CONSERVATION
![Page 64: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/64.jpg)
Local recurrences after BCS + RT BOOST versus NO BOOST
no boost boost H.R.
• Lyon 5 y 4.5 % 3.6 % (10 Gy) 0.80 p = 0.044
n = 1024
• French M.C. 5 y 6.8 % 3.6 % (16Gy) 0.53 p = 0.13
n = 664
• EORTC 10801 5 y 6.8 % 3.4 % (15Gy) 0.59 p = 0.0001
n = 5569
BREAST CONSERVATIONBREAST CONSERVATION
![Page 65: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/65.jpg)
BREAST-RT +/- BOOSTBREAST-RT +/- BOOST
p=0.002 p=0.02
p=0.07 p=0.11
- 40J (n=449) 41-50J (n=1334)
51-60J (n=1803) > 60J (n=1732)
Bartelink et al., NEJM 2001
BREAST CONSERVATIONBREAST CONSERVATION
![Page 66: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/66.jpg)
Breast pain – randomised study
Whelan et al., Cancer 2000
no RT
RT
*
*
p<0.01
BREAST CONSERVATIONBREAST CONSERVATION
![Page 67: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/67.jpg)
Skin reactions – randomised study
RT
no RT
Whelan et al., Cancer 2000
*
*
p<0.01
BREAST CONSERVATIONBREAST CONSERVATION
![Page 68: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/68.jpg)
Breast cosmesis – randomised study
Whelan et al., Cancer 2000
no RT
RT
BREAST CONSERVATIONBREAST CONSERVATION
![Page 69: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/69.jpg)
Global score by boost treatment
No boost Boost0
20
40
60
80
100%
Excellent/Good
Fair/Poor
71%
29%
86%
14%
BREAST CONSERVATIONBREAST CONSERVATION
![Page 70: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/70.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
![Page 71: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/71.jpg)
CONCLUSIONCONCLUSION
• BCT + Mastectomy equivalent !• BC surgery: No omission of RT !• No omission of RT in ‚low risk‘ !• The target is the whole breast !• There are equivalent schedules !• Boost efficient (! <50yrs !)
BREAST CONSERVATIONBREAST CONSERVATION
![Page 72: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/72.jpg)
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
![Page 73: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/73.jpg)
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
![Page 74: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/74.jpg)
‚‚TIMING‘ RT – HTTIMING‘ RT – HT
In vitro
Radioresistence , Ø, by Tamoxifen
In vivo
Only 2 studies(Labrie et al.; Cancer Res. 1999; Int J Cancer 2003)
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
![Page 75: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/75.jpg)
‚‚TIMING‘ RT – HTTIMING‘ RT – HT
ZR-75-1 human breast cancer cells (s.c. into nude mice)=> average tumor-area 20mm2; Strata: tumor size
RT 15x2GyEM-800 300ug/d (SERM)
Day 1 21 156
ARM A
ARM B
CR: 62% CR: 62% (arm A) vs. 22% vs. 22% (arm B)
RRT 15x2Gy
EM-800 300ug/d (SERM)
24 mice
24 mice
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
![Page 76: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/76.jpg)
RT – Tamoxifen: simultaneous vs sequentialRT – Tamoxifen: simultaneous vs sequential
Journal of Clinical Oncology, Vol 23, No 1, 2005* 3 (small) retrospective studies
LRFSOS
z.B. Ahn et al, 2005
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
![Page 77: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/77.jpg)
Lokalrezidiv
Bentzen, S. M. et al. JCO; 23:6266-6267 2005
RT – Tamoxifen: simultaneous vs sequentialRT – Tamoxifen: simultaneous vs sequential
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
![Page 78: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/78.jpg)
RT – 6xCMF: ‚RT first‘ vs ,CMF first‘RT – 6xCMF: ‚RT first‘ vs ,CMF first‘
Bellon, J. R. et al. JCO; 23:1934-1940; 2005
DFS
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
Breast conservation; n=244
No significant difference!
![Page 79: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/79.jpg)
RT – 6xCMF: ‚RT first‘ vs ,CMF first‘RT – 6xCMF: ‚RT first‘ vs ,CMF first‘
Bellon, J. R. et al. JCO; 23:1934-1940; 2005
DMFSDFS
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
Breast conservation; n=244
No significant difference!
![Page 80: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/80.jpg)
RT – 6xCMF: ‚RT first‘ vs ,CMF first‘RT – 6xCMF: ‚RT first‘ vs ,CMF first‘
Bellon, J. R. et al. JCO; 23:1934-1940; 2005
No significant difference!
Breast conservation; n=244
OSDMFSDFS
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
![Page 81: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/81.jpg)
‚‚ChT => RT‘ vs ,simChT/RT‘ChT => RT‘ vs ,simChT/RT‘
Toledano et al.; Int J Radiat Oncol Biol Phys; 2006
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
ChT= mitoxantrone, 5-FU, cyclophosphamide; 6 cyclesRT= 50Gy/2Gy; +/- boost
ARCOSEIN III trial (n=214 for late toxicity)
! No difference in acute toxicity !(skin, esophagus, infections, neutropenia)! No statistical difference in grade 2 or higherbreast edema, lymphedema, pain !! simChT/RT: Significant more breast atrophy,subcutaneous fibrosis, teleangiectasia, skin pigmentation !
![Page 82: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/82.jpg)
RT – Herceptin ®RT – Herceptin ®
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
![Page 83: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/83.jpg)
RT – Herceptin ®RT – Herceptin ®
Halyard MY et al. ASCO; 2006
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
N9831: AC->T->H vs AC->TH->HRT (after BCS or Mx4+LN sim to H allowed)
1460 available for adverse events analysesmedian f-up: 1.5yrs
Skin reaction (p=0.78); pneumonitis (p=0.78), dyspnea (p=0.87)Cough (p=0.54); dysphagea (p=0.26); neutropenia (p=0.16)
Concurrent H-RT is not associated with acute RT adverse events Further follow up is needed for late adverse events
![Page 84: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/84.jpg)
IndividualHT: simultaneous possibleChT: In most centers: ChT -> RT
simultaneous RChT possible but more side effects!=> Not recommended
RT – BREAST CANCERRT – BREAST CANCER‚‚TIMING‘TIMING‘
How to combine RT with systemic therapies ?
Herc: simultaneous possible
![Page 85: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/85.jpg)
TECHNIQUE / RT APPLICATIONTECHNIQUE / RT APPLICATION
BREAST CONSERVATIONBREAST CONSERVATION
![Page 86: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/86.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
![Page 87: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/87.jpg)
Planning-CT and 3D-Planning
BREAST CONSERVATIONBREAST CONSERVATION
![Page 88: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/88.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
![Page 89: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/89.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
![Page 90: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/90.jpg)
Hurkmans et al., 2001Hurkmans et al., 2001
42 mm
HEART
BREAST CONSERVATIONBREAST CONSERVATION
![Page 91: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/91.jpg)
![Page 92: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/92.jpg)
„Open“ homogeneous beam (OB)
Intensity modulatedbeam (IMB)
BREAST CONSERVATIONBREAST CONSERVATION
IMRT
![Page 93: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/93.jpg)
BREAST CONSERVATIONBREAST CONSERVATION
IMRT
![Page 94: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/94.jpg)
IMRT
IMRT
IMRT
BREAST CONSERVATIONBREAST CONSERVATION
![Page 95: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/95.jpg)
R
Standard 2D 3D IMRT
5yrs – Differences in breast appearence (Photos)
60% 48% p=0.06
(QoL no difference)
n=306
Yarnold et al., ECCO 13; 2005
BREAST CONSERVATIONBREAST CONSERVATION
IMRT
![Page 96: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/96.jpg)
6MV + 12e Protons
IMRTIMRTLomax et al. IJROBP 2003
BREAST CONSERVATIONBREAST CONSERVATION
![Page 97: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/97.jpg)
‚Organ‘motion, n=20
‚motion‘ within 1 fraction: 1.3 +/- 0.4 mm‘motion’ between 2 fractions: 2.6 +/- 1.3 mm
Kron et al., ESTRO 2004
BREAST CONSERVATIONBREAST CONSERVATION
![Page 98: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/98.jpg)
SCHLUSSFOLGERUNGSCHLUSSFOLGERUNG
BREAST CONSERVATIONBREAST CONSERVATION
![Page 99: GÜNTHER GRUBER Institut für Radio-Onkologie guenther.gruber @ ksa.ch RADIOTHERAPY IN BREAST CANCER (PART 1: CONSERVATION)](https://reader035.fdocuments.in/reader035/viewer/2022062519/56649ddf5503460f94ad8003/html5/thumbnails/99.jpg)
RT – BREAST CANCERRT – BREAST CANCERRE-IRRADIATIONRE-IRRADIATION