DCIS and radiotherapy: still for all?

Transkript

1 DCIS and radiotherapy: still for all? No Conflicts of Interest G.Fastner, MD UC Radiotherapy and Radio-Oncology

2 Epidemiology of DCIS About 20 % of all breast cancer cases Incidence /year (US) 90% detected by mammography (Microcalcification 76%) Up to 60 % multifocal, discontinous expansion Burstein et al Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 2

3 Therapy Mastectomy Breast conserving surgery (BCS) plus whole breast irradiation (WBI) Antihormonal therapy: Pos HR-status (70%): Reduction of ipsilat. In breast relapses/ contralateral breast cancer [Staley H et al,cochrane systematic review and metaanalysis, The Breast 2014] Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 3

4 Planning target volume (PTV)? Target: Dosage: Technique breast tissue without chest wall dosage: 50 Gy in 2.0 Gy/fx, 5x/Week 2 tangential Fields, isocentric technique PTV-determination, CT based Dose distribution Fixation isocenter Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 4

5 n=

6 LRR (any) OS Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 6

7 LRR Tumorsize RT eliminates tumorsize as a risk factor 7

8 LRR Age EBCTCG LRR-Alter Benefit of RT is greater in elderly (>50 years) 8

9 LRR Tamoxifen EBCTCG- LRR Tam vs. kein Tam -Tam +Tam Benefit of RT seemed to be smaller in Tam + 9

10 LRR Tumorgrading Benefit of RT is greater in high histological grade Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 10

11 LRR Comedonecrosis Benefit of RT is greater in present comedonecrosis Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 11

12 Riskfactors for in breast relapses Bijker N. et al JCO 2006 (24): Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 12

13 Summary Overview EBCTCG randomised patients FUP: Mean: 10 years (4,8 16,5) RTX halfens the rate IBR independently of: Age (</> 50J), +/-Tamoxifen, marginstatus, focality, grading, comedonecrosis,size 10 year risk reduction with RTX of 15% (12.9% vs. 28.1%, p< ) The higher the age the higher the proport. LR-decrease (sign.) No difference of OS Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 13

14 Recommendations Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 14

15 Recommendations After BCS, RT is recommended as whole breast irradiation. No subgroup was definded, who does not benefit from RT regarding LC. Is Supported by: National Institutes of Health State-of-the-Science Conference statement: diagnosis and management of ductal carcinoma in situ (2009) [Allegra CJ et al 2010, J Natl Cancer Inst 102: ]. Cochrane Database analysis (2013): Post-operative radiotherapy for ductal carcinoma in situ of the breast [Goodwin A et al 2013, Cochrane database Syst Rev doi: / ] Review (2009): Post-operative radiotherapy for ductal carcinoma in situ of the breast a systematic review of the randomised trials [Goodwin A et al 2009: Breast 18: ] Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 15

16 Low Risk subgroups small RT Benefit? Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 16

17 Profile of the Relative failure Risk Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 17

18 Score Calculation Risk groups? low intermediate high Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 18

19 Results risk groups low + RT intermediate RT high + RT RT Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 19

20 Results margin status RT + RT + RT RT Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 20

21 Results margin 10 mm? Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 21

22 VNPI update Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 22

23 Margin status Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 23

24 Margin status Dunne C et al 2009 JCO Wang Shi-Yi et al 2012 JNCI Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 24

25 Prospective results of low risk patients: BCS +/ WBI? Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 25

26 Inclusion criterions/design Inclusion: Size: < 25 mm Unicentric N=298 Margins > 3mm G1/2 DCIS N=287 RT < 12 w after OP Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 26

27 Patients Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 27

28 Results Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 28

29 Recommendations Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 29

30 Recommendations DEGRO: There exists no subgroup of patients, without RTX-benefit EIO: No RTX: G1/2 without comedonecrosis St. Gallen-C. (2011):..some elderly patients, low-grade, low-risk could omit from RT after complete BCS. NCCN: Maybe some patients could be treated with excision alone if the individual risk is caculated as low Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 30

31 Comparison US/Europe? Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 31

32 Conclusion WBI after BCS halfens the ocurrence of in breast relapses. The benefit is independently of: age, grading, size, marginstatus, antihormonal therapy. RT does not influence OS. Treatment-guidlines underline the effect of RT regarding LC recommendations according to low-risk subgroups are inconsistent Multigene expression assays, for the prediction for LR-risk, are in investigation Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 32

33 Gemeinnützige Salzburger Landeskliniken Betriebsges.m.b.H 33