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Doç. Dr. Merdan Fayda
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KRK %25 başvuruda %50’si takipte KC met’i Kolorektal, mide, pankreas, meme, akciğer,
melanom… Metastazektomi – uzun sk ile ilişkili olabilir ◦ Kolorektal, meme, noroendokrin, sarkom …
Schefter, SRO,2011
UKK 2013
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Hellman ve Weichselbaum, JCO ,1995 Weichselbaum ve Hellman, Nat Rev Clin Oncol, 2011
Kısıtlı metastatik kapasiteli tümör
Pratikte 1-6 metastaz
UKK 2013
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RCC akciğer metleri oligo (<8 met) vs. multi (>16) hücre bölünmesi ve siklusle ilgili genlerde (PBK, BIRC5, PTTG1) ekspr.
Wuttig, Int J Cancer, 2009 UKK 2013
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Oligometastatik olgular
◦ Oligometle başvuran
◦ Sitoredüktif sistemik tedavi sonrası oligometastatik hale gelmiş [başvuruda oligometten daha kötü prognozlu]
◦ Küratif lokal bölgesel tedavi sonrası oligometle nüks etmiş olgular
Tree AC, Lancet Oncol, 2013 UKK 2013
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Bilgi kaynağı cerrahi serilerden
Randomize data yok
Pozitif CS (5 yıl SK %17 vs %63) >3 met CEA>200ng/ml
Weichselbaum, Nat Rev Clin Oncol, 2011
(CRC)
UKK 2013
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Fong, Ann Surg, 1999
Nod + primer Hastalıksız interval < 1 yıl >1 met boyut > 5 cm CEA>200 ng/ml
UKK 2013
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Uzun hastalıksız interval
Meme histolojisi
1-3 metastaz
Küçük metastazlar
Tree AC, Lancet Oncology, 2013 UKK 2013
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UKK 2013
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Nasıl ?
Solunum hareket -tümör takibi
Görüntü aracılı yöntemlerle hasta pozisyon kontrolü
UKK 2013
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Solunum hareketini azaltma
Abdominal kompresyon
Scorsetti, IJROBP, 2013 UKK 2013
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Nasıl ?
Solunum hareketini takip
UKK 2013
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Solunum hareketini takip
UKK 2013
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Planlama amaçlı kontrastlı BT
MRG füzyon yapılabilir
UKK 2013
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PTV ekspansiyon
◦ PTV= Aksiyel GTV + 5-13mm Superoinferior GTV + 10-13mm
◦ PTV = ITV+ 5 mm
Schefter, SRO, 2011 UKK 2013
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45-60 Gy/ 3 fr / haftada 2 kez 60 Gy / 5 fr / haftada 2 kez
UKK 2013
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Karaciğer
◦ Met dışı karaciğer > 700 cm3 Dmax < 15 Gy (3-5fr için)
◦ 700cc KC 9,1Gy / 1fr 19,2Gy / 3 fr 21Gy / 5fr
Marks, IJROBP, 2011 Benedict, TG101Med Phys, 2010
UKK 2013
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Marks, IJROBP, 2011 Benedict, TG101Med Phys, 2010 Bae, IJROBP, 2012
202 hst, 3 fr ve ↗ Gastroduodenum dozu Dmax 35 Gy % 5 ciddi GDT
Dmax 38 Gy % 10 ciddi GDT
Ülser hikayesi etkili
UKK 2013
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Benedict, TG 101, Med Phys, 2010 Petterson, RO, 2010 Dunlop, IJROBP, 2010
D2cc Kaburga Kırığı
<21 Gy / 3fr % 0
< 27,3 Gy / 3fr %5
<48,5 Gy / 3fr %50
30 Gy /3-5 fr V30 > 30 mL kaburga kırığı / narkotik analjezik gerektiren göğüs ağrısı
UKK 2013
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Solunum hareketi-tümör
takibi
Altın markerlarla
UKK 2013
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UKK 2013
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UKK 2013
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Hasta/ Lezyon
Doz Hedef medyan
mL
Takip Lokal kontrol
Toksisite
Herfath, 2004
33 / 56
14-26 Gy/ 1 fr
10 (1-132) 5,7 ay
%71 1,5y %67
?
Mendez, 2008
17 met 30-37,5 Gy / 3 fr
22,2 (1,1-322)
? 2y %86 2y GS %62
2 gr 3 KC tox
Rusthoven, 2009
47 Doz ↗, 36-60 Gy
/3 fr
14,93 (0,75-97,98)
16 ay 1y %95 2y %92
(tm< 3cm %100) MedSK 20,5ay
RIKH yok Geç gr 3-4 <%2
Lee, 2009 68 27,7-60 Gy / 3 fr
75,9 (1,2-3090)
10,8 ay
1y %71 Med SK 17,6ay
RIKH yok Ak. gr3-4 %10 Kr. Gr 3-4 yok
Scorsetti, 2013
61 / 76
75 Gy / 3fr
54,9 (7,7-209,4)
12 ay
1y %94 Med SK 19
ay 1y akt. SK
%83,5
%26 Gr 2 KC enzim↗,
Gr1 Yorgunluk %65,
1hst Gr 3 kr göğüs ağrısı
UKK 2013
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Cevap Değerlendirme ?
Kontrastlı USG (preliminer rapor)
BT – Yaygın kolay ulaşılır
MRG –
PET-BT -
UKK 2013
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Cevap Değerlendirme ?
BT – Yaygın kolay ulaşılır
Jarraya, Radiat Oncol, 2013 UKK 2013
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Cevap Değerlendirme ?
Jarraya, Radiat Oncol, 2013 UKK 2013
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Cevap Değerlendirme ?
Jarraya, Radiat Oncol, 2013 UKK 2013
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Cevap Değerlendirme ?
Jarraya, Radiat Oncol, 2013 UKK 2013
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Cevap Değerlendirme ?
Jarraya, Radiat Oncol, 2013 UKK 2013
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Cevap Değerlendirme ?
PET-BT – uzak kontrol hakkında da fikir verir BT ile stabil hastalığı daha iyi yorumlayabilir
Solanki, Radiat Oncol, 2012 UKK 2013
PET-CR: Normal tutulum PET-PR: SUVmax’ta >%30 azalma PET –SD: SUVmax <%30 az. <%20 art. PET-PD: SUVmax > %20 artış
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Cevap Değerlendirme ? PET-BT
Solanki, Radiat Oncol, 2012 UKK 2013
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Cevap Değerlendirme ?
MRG- Yumuşak doku rezolusyonu farklı sekanslar, difüzyon, perfüzyon, substraksiyon
PET ve BT’nin göremediği lezyonları görebilir
UKK 2013
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Cevapsız Olgular
Re-Radyocerrahi ◦ 45 Gy / 3 fr (ilk tedaviden 10 ay sonra, grad 2 asit ve dekompensasyan )
UKK 2013 Jarraya, Radiat Oncol, 2013
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Nasıl ?
Teknik Hekim
Stereotaktik RT
Cerrahi Radyonüklid RF ve diğer
Medikal Onkolog
+ + + +
Girişimsel
Radyolog +/- - + +
Radyasyon
Onkoloğu + - - -
Nükleer Tıp Uzm. - - + -
Karaciğer Cerrahı - + - -
6.000 TL 3.000-10.000 20.000-30.000 3.000 UKK 2013
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RF ablasyon vs. SRT in Colorectal Liver Metastases (RAS01), Danimarka
Age: 18 Years to 90 Years
Inclusion Criteria: Adenocarcinoma of the colon or rectum Liver metastases Inoperable (technical or medical) 1-4 metastases Maximum 40 mm in diameter Suitable for both therapies, RFA and SBRT
Exclusion Criteria: Uncontrolled extrahepatic disease and uncontrolled primary cancer Liver cirrhosis
UKK 2013
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Karaciğer metlerinde SBRT Az sayıda metastaz (1-3) Uzun hastalıksız SK (>1yıl) Luminal Gastrointestinal organlardan uzak (>1,5 cm) Çok büyük olmayan metlerde (< 6cm) Vücuttaki hastalık kontrol altında Diğer lokal ablatif tedavilere aday olmayan olgularda
Düşük toksisite ve güvenle uygulanabilir.
UKK 2013