vakalis breast radiotherapy

FUZZ-IEEE 2009

Ακτινοθεραπεία Ca μαστού ενδείξεις ανά στάδιο

ειδικές ομάδες ασθενών

Ακτινοθεραπευτής Ογκολόγος Euromedica – Αθήναιον Α Ιατρικό Κέντρο Αθηνών

Βακάλης Ξενοφών

Breast cancer

Breast cancer

FUZZ-IEEE 2009

Radiotherapy in DCISDuctal Carcinoma In-Situ

Radiotherapy in DCIS

Radiotherapy in DCIS

FUZZ-IEEE 2009

Radiotherapy in DCISDuctal Carcinoma In-Situ

Radiotherapy in DCIS

Radiotherapy in DCIS

Breast Cancer Nomogram: Ductal Carcinoma In Situ (DCIS) Recurrence

Breast Cancer Nomogram: Ductal Carcinoma In Situ (DCIS) Recurrence

Radiotherapy in DCIS

OncoTypeDXfor Estimating Recurrence Risk After Lumpectomy with No Radiation

Score Any Recurrence Invasive Recurrence

Low Risk 12% 5%

Intermediate Risk 25% 9%

High Risk 27% 19%

E5194 study

http://www.genomichealth.com/en-US/OncotypeDX.aspx further validation of these results is required

Radiotherapy in DCIS

Radiotherapy in early stage invasive BC

clinical stage I, IIA, or a subset of stage IIB disease (T2N1)

Radiotherapy in early stage invasive BC

Radiotherapy in early stage invasive BC

Radiotherapy in early stage invasive BC

EBCTCG Meta-analysis of BCS +/- RT

(EBCTCG, Lancet 366:17,2005)

FUZZ-IEEE 2009

Radiotherapy in early stage invasive breast cancer

Radiotherapy in early stage invasive BC

Radiotherapy in early stage invasive BC

Radiotherapy in early stage invasive BC

Radiotherapy in early stage invasive BC

Radiotherapy in early stage invasive BC

Radiotherapy in early stage invasive BC

Radiotherapy in early stage invasive BC

Radiotherapy in early stage invasive BC

FUZZ-IEEE 2009

Nodal Radiotherapy

www.wondershare.com

Nodal Radiotherapy

www.wondershare.com

Nodal Radiotherapy

www.wondershare.com

Nodal Radiotherapy

www.wondershare.com

Nodal Radiotherapy

www.wondershare.com

Nodal Radiotherapy

www.wondershare.com

Nodal Radiotherapy

www.wondershare.com

Nodal Radiotherapy (IMN)

MA-20

Nodal Radiotherapy (IMN)

www.wondershare.com

Nodal Radiotherapy (IMN)

How to Manage Axilla in cN0 after SLNDSLND

Negative SLNNo additional axillary treatment necessary•Milan trial, SLN = ALND•NSABP B-32, SLN = ALND

Positive SLN•Full node dissection•No Axillary treatment

• ACOSOG Z0011 •IBCSG 23-01 •AMAROS

How to Manage Axilla after SLND

www.wondershare.com

How to Manage Axilla after SLND

www.wondershare.com

How to Manage Axilla after SLND

High Tangents Cover Most ofLevel I/II Axilla

• High tangent fields includes most of area at risk

• Superior border: Just below humeral head

• Posterior border: 2 cm within the lung includes:– over 95% of SLN– over 80% of level I and II axilla

Schlembach, Int J Rad Oncol Biol Phys, 2001

How to Manage Axilla after SLND

www.wondershare.com

How to Manage Axilla after SLND

AMAROS

Standard ALND Radiotherapy P-value

5-year Axillary Recurrence rate 0.54% (4/744) 1.03% (7/681)

5-year Overall Survival Rate 93.3 92.5 0.338

5-year Disease-free Survival Rate 86.9 82.7 0.179

ASCO 2013

Nodal Radiotherapy

AMAROS

MA20N+

MA20High risk

N0

FUZZ-IEEE 2009

Post-Mastectomy Radiotherapy

Post-Mastectomy Radiotherapy

Limit LRR 15% for RT

Post-Mastectomy Radiotherapy

Post-Mastectomy RadiotherapyIndications for PMRT

G.M. Freedman ASTRO Spring Refresher Course 2013

Post-Mastectomy Radiotherapy

Post-Mastectomy Radiotherapy

Post-Mastectomy RadiotherapyIndications for PMRT

G.M. Freedman ASTRO Spring Refresher Course 2013

FUZZ-IEEE 2009

Tumor Bed Boost

www.wondershare.com

Tumor Bed BoostStage I-II

www.wondershare.com

Tumor Bed Boost

www.wondershare.com

Tumor Bed Boost

No difference in overall survival, breast cancer mortality, or disease-free survival at 10 years

Effects of Boost on 10-Year LRby Age & Grade

Bartelink H, et al., J Clin Oncol 2007Jones, H. A. et al. J Clin Oncol 2009

www.wondershare.com

Tumor Bed Boost

NCCN Guidelines Version 3.2013

• The breast should receive a dose of 45-50 Gy in 1.8 – 2 Gy per fraction, 42.5 Gy at 2.66 Gy per fraction.

• A boost to the tumor bed is recommended for patients in higher risk for local failure:– Age < 50– Positive lymph nodes– LVI– Close margins

www.wondershare.com

Tumor Bed Boost (DCIS)

NCIC CTG MA.33

www.wondershare.com

Tumor Bed Boost

FUZZ-IEEE 2009

Radiotherapy after Neoadjuvant Chemotherapy

www.wondershare.com

Radiotherapy after Neoadjuvant Chemotherapy

lack of prospective data

www.wondershare.com

Radiotherapy after Neoadjuvant Chemotherapy

www.wondershare.com

Radiotherapy after Neoadjuvant Chemotherapy

FUZZ-IEEE 2009

Radiotherapy after Neoadjuvant Chemotherapy

www.wondershare.com

Radiotherapy after Neoadjuvant Chemotherapy

FUZZ-IEEE 2009

Radiotherapy after Neoadjuvant Chemotherapy

www.wondershare.com

Radiotherapy after Neoadjuvant Chemotherapy

www.wondershare.com

Radiotherapy after Neoadjuvant Chemotherapy

www.wondershare.com

Radiotherapy after Neoadjuvant Chemotherapy

FUZZ-IEEE 2009

Whole Breast Hypofractionation

www.wondershare.com

Whole Breast Hypofractionation

www.wondershare.com

Whole Breast Hypofractionation

www.wondershare.com

Whole Breast Hypofractionation

www.wondershare.com

Whole Breast Hypofractionation

www.wondershare.com

Whole Breast Hypofractionation

www.wondershare.com

Whole Breast Hypofractionation

NCCN-No

www.wondershare.com

ACCELERATED PARTIAL BREAST IRRADIATION

www.wondershare.com

ACCELERATED PARTIAL BREAST IRRADIATION

Radiotherapy in invasive BC

Individualized Radiotherapy in BC

A lot of subgroups

No RT of breast in DCISNo RT of breast in early stage of invasive caNo boostHypofractionated RT of whole breastAccelerated Partial RT

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