Akselere Parsiyel Meme Radyoterapisi Akselere Parsiyel Meme Radyoterapisi
Özet
Meme koruyucu cerrahi sonrası uygulanan Akselere Parsiyel Meme Radyoterapisi (APBI), standart 6 haftalık tüm meme radyoterapisine (WBRT) efektif, daha kısa süreli ve yan etki profili düşük bir alternatif olarak geliştirilmiştir. Lokal nükslerin büyük oranda tümör yatağı çevresinde gelişmesi esasına dayanan bu yaklaşım; multikateter interstisyel implantasyon, Mammosite balon kateter, eksternal radyoterapi (EBRT) ve intraoperatif radyoterapi (IORT) gibi farklı tekniklerle uygulanabilmektedir. Tedavinin başarısı; hastanın yaşı, tümör boyutu ve cerrahi sınır durumu gibi parametrelere göre yapılan doğru hasta seçimine ve hassas hedef volüm (CTV/PTV) tanımlamasına doğrudan bağlıdır. Bu kapsamda ASTRO ve GEC-ESTRO gibi kuruluşlar hastaları uygun, tartışmalı ve uygun olmayan şeklinde gruplandıran kılavuzlar yayınlamıştır. NSABP B-39/RTOG 0413 gibi geniş ölçekli klinik çalışmalar, APBI'nın WBRT ile tam eşdeğerliğini kanıtlayamasa da seçilmiş hasta gruplarında güvenilir bir alternatif olduğunu ortaya koymuştur. Özellikle IORT tekniği, operasyon sırasında tek dozda uygulanabilmesi ve cilt koruyucu etkisiyle kozmetik açıdan avantaj sağlamaktadır. Sonuç olarak APBI, uygun teknik ve doğru hasta seçimiyle erken evre meme kanseri yönetiminde etkinliğini her geçen gün artıran standart bir tedavi seçeneği haline gelmektedir.
Accelerated Partial Breast Irradiation (APBI), administered after breast-conserving surgery, has been developed as an effective, shorter, and lower-toxicity alternative to the standard 6-week whole breast radiotherapy (WBRT). Based on the rationale that the majority of local recurrences occur near the tumor bed, this approach can be delivered via various techniques including interstitial multicatheter implantation, MammoSite balloon catheter, external beam radiotherapy (EBRT), and intraoperative radiotherapy (IORT). The success of the treatment depends heavily on accurate patient selection based on parameters like age, tumor size, and margin status, as well as precise target volume (CTV/PTV) delineation. Consequently, organizations such as ASTRO and GEC-ESTRO have published guidelines categorizing patients into suitable, cautionary, and unsuitable groups. Large-scale clinical trials, such as NSABP B-39/RTOG 0413, could not definitively prove the equivalence of APBI to WBRT, but demonstrated that it is a viable alternative for selected low-risk patients. Specifically, the IORT technique stands out by delivering a single fraction during surgery, minimizing skin toxicity, and providing superior cosmetic outcomes. In conclusion, when combined with appropriate techniques and strict patient criteria, APBI is becoming an effective standard treatment alternative in early-stage breast cancer management.
Referanslar
National Institutes of Health Consensus Development Conference Statement: Adjuvant therapy for breast cancer, November 1–3, 2000. J Natl Cancer Inst Monogr 2001;2001(30):5–15.
Holland R, Connolly JL, Gelman R, et al. The presence of an extensive intraductal component following a limited excision correlates with prominent residual disease in the remainder of the breast. J Clin Oncol. 1990;8:113–118.
Mannino M, Yarnold J. Accelerated partial breast irradiation trials: diversity in rationale and design. Radiother Oncol. 2009;91:16–22.
Offersen BV, Overgaard M, Kroman N, et al. Accelerated partial breast irradiation as part of breast conserving therapy of early breast carcinoma: a systematic review. Radiother Oncol. 2009;90:1–13.
Vicini FA, Arthur DW. Breast brachytherapy: North American experience. Semin Radiat Oncol. 2005;15:108–115.
Shah NM, Wazer DE. The MammoSite balloon brachytherapy catheter for accelerated partial breast irradiation. Semin Radiat Oncol. 2005;15:100–107.
Strauss JB, Dickler A. Accelerated partial breast irradiation utilizing balloon brachytherapy techniques. Radiother Oncol. 2009;91:157–165.
Pignol JP, Rakovitch E, Keller BM, et al. Tolerance and acceptance results of a palladium-103 permanent breast seed implant Phase I/II study. Int J Radiat Oncol Biol Phys. 2009;73:1482–1488.
Vaidya JS, Baum M, Tobias JS, et al. Targeted intra-operative radiotherapy (Targit): an innovative method of treatment for early breast cancer. Ann Oncol. 2001;12:1075–1080.
Veronesi U, Gatti G, Luini A, et al. Full-dose intraoperative radiotherapy with electrons during breast-conserving surgery. Arch Surg. 2003;138:1253–1256.
Beal K, McCormick B, Zelefsky MJ, et al. Single-fraction intraoperative radiotherapy for breast cancer: early cosmetic results. Int J Radiat Oncol Biol Phys. 2007;69:19–24.
Formenti SC, Rosenstein B, Skinner KA, et al. T1 stage breast cancer: adjuvant hypofractionated conformal radiation therapy to tumor bed in selected postmenopausal breast cancer patients–pilot feasibility study.Radiology. 2002;222:171–178.
Baglan KL, Sharpe MB, Jaffray D, et al. Accelerated partial breast irradiation using 3D-conformal radiation therapy (3D-CRT). Int J Radiat Oncol Biol Phys. 2003;55:302–311.
Moran JM, Ben-David MA, Marsh RB, et al. Accelerated partial breast irradiation: what is dosimetric effect of advanced technology approaches? Int J Radiat Oncol Biol Phys. 2009;75:294–301.
Kozak KR, Doppke KP, Katz A, et al. Dosimetric comparison of two different three-dimensional conformal external beam accelerated partial breast irradiation techniques. Int J Radiat Oncol Biol Phys. 2006;65:340–346.
Galland-Girodet S, Pashtan I, MacDonald SM, et al. Long-term cosmetic outcomes and toxicities of proton beam therapy compared with photon-based 3-dimensional conformal accelerated partial-breast irradiation: a phase 1 trial. Int J Radiat Oncol Biol Phys. 2014;90:493–500.
Strom EA, Amos RA, Shaitelman SF, et al. Proton partial breast irradiation in the supine position: treatment description and reproducibility of a multibeam technique. Pract Radiat Oncol. 2015;5:e283–e290.
Benjamin D. Smith, M.D., Douglas W. Arthur, M.D., Thomas A. Buhholz, M.D., et al. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO) Int. J. Radiation Oncology Biol. Phys., Vol. 74, No. 4, pp. 987–1001, 2009
Correa Candace, Harris Eleanor E, Leonardi Maria Cristina, et al Accelerated Partial Breast Irradiation: Executive Summary for the Update of an ASTRO Evidence-Based Consensus Statement, Practical Radiation Oncology (2016), doi: 10.1016/j.prro.2016.09.00
Vratislav Strnad , Tibor Major, Csaba Polgar, et al.ESTRO-ACROP guideline: Interstitial multi-catheter breast brachytherapy as Accelerated Partial Breast Irradiation alone or as boost– GEC-ESTRO Breast Cancer Working Group practical recommendations. Radiotherapy and Oncology 128 (2018) 411–420
Pierquin B, Wilson JF, Chassagne D. The Paris system. Modern brachytherapy. Masson Pubklishing USA, Inc.; 1987.
Gutierrez C, Najjari D, Martinez E, Botella S, Eraso A, Pino F, et al. The use of an interstitial boost in the conservative treatment of breast cancer: how to perform it routinely in a radiotherapy department. J Contemp Brachytherapy 2015;6:397–403.
Strnad V, Hannoun-Levi JM, Guinot JL, Lossl K, Kauer-Dorner D, Resch A, et al. Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery. Radiother Oncol 2015;115:342–8.
Fitzal F, Nehrer G, Hoch D, et al. An oncoplastic procedure for central and medio-cranial breast cancer. Eur J Surg Oncol 2007;33:1158–63
Roth AM, Resch A, Kauer-Dorner D. Is oncoplastic surgery a contraindication for accelerated partial breast radiation (APBI) using the interstitial multicatheter brachytherapy method? Brachytherapy 2014;13:394–9.
Major T, Gutierrez C, Guix B, van Limbergen E, Strnad V, Polgar C, et al. Recommendations from GEC ESTRO Breast Cancer Working Group (II): Target definition and target delineation for accelerated or boost partial breast irradiation using multicatheter interstitial brachytherapy after breast conserving open cavity surgery. Radiother Oncol 2016;118:199–204.
Strnad V, Ott OJ, Hildebrandt G, Kauer-Dorner D, Knauerhase H, Major T, et al. 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet 2016;387:229–38.
Hannoun-Levi JM, Resch A, Gal J, Kauer-Dorner D, Strnad V, Niehoff P, et al. Accelerated partial breast irradiation with interstitial brachytherapy as second conservative treatment for ipsilateral breast tumour recurrence: multicentric study of the GEC-ESTRO Breast Cancer Working Group. Radiother Oncol 2013;108:226–31.
Frank A Vicini, Reena S Cecchini, Julia R White, et al.Long-term primary results of accelerated partial breast irradiation after breast-conserving surgery for early-stage breast cancer: a randomised, phase 3, equivalence trial Lancet. 2019 Dec 14;394(10215):2155-2164.
Arthur DW, Vicini FA. MammoSite RTS: the reporting of initial experiences and how to interpret. Ann Surg Oncol 2004;11(8):723–724.
Keisch M, Vicini F, Kuske RR, et al. Initial clinical experience with the MammoSite breast brachytherapy applicator in women with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 2003;55(2):289–293.
Sharad Goyal, Thomas Buchholz, and Bruce G. Haffty , Breast Cancer: Early Stage, Perez and Brady’s principles and practice of radiation oncology / [edited by] Edward C. Halperin,David E. Wazer, Carlos A. Perez, Luther W. Brady. Seventh edition. | Philadelphia : Wolters Kluwer, 2018, (pp 5451)
Vicini F, Beitsch P, Quiet C, et al. Five-year analysis of treatment efficacy and cosmesis by the American Society of Breast Surgeons MammoSite Breast Brachytherapy Registry Trial in patients treated with accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys 2011;79(3):808–817.
Formenti SC. External-beam partial-breast irradiation. Semin Radiat Oncol 2005;15(2):92–99.
Vicini F, Winter K, Straube W, et al. A phase I/II trial to evaluate three dimensional conformal radiation therapy confined to the region of the lumpectomy cavity for stage I/II breast carcinoma: initial report of feasibility and reproducibility of Radiation Therapy Oncology Group (RTOG) Study 0319. Int J Radiat Oncol Biol Phys 2005;63(5):1531–1537.
Vicini F, Winter K, Wong J, et al. Initial efficacy results of RTOG 0319: three-dimensional conformal radiation therapy (3D-CRT) confined to the region of the lumpectomy cavity for stage I/II breast carcinoma. Int J Radiat Oncol Biol Phys 2010;77(4):1120–1127.
Olivotto IA, Whelan TJ, Parpia S, et al. Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy. J Clin Oncol 2013;31(32):4038–4045.
Sedlmayer F, Reitsamer R, Wenz F, Sperk E, Fussl C, Kaiser J, et al. Intraoperative radiotherapy (IORT) as boost in breast cancer. Radiation oncology (London, England). 2017;12:23.
Belletti B, Vaidya JS, D'Andrea S, Entschladen F, Roncadin M, Lovat F, et al. Targeted intraoperative radiotherapy impairs the stimulation of breast cancer cell proliferation and invasion caused by surgical wounding. Clin Cancer Res. 2008;14:1325-32.
Veldwijk MR, Neumaier C, Gerhardt A, Giordano FA, Sütterlin M, Herskind C, et al. Comparison of the proliferative and clonogenic growth capacity of wound fluid from breast cancer patients treated with and without intraoperative radiotherapy.Translational Cancer Research. 2015;4:173-7.
Herskind C, Wenz F. Radiobiological aspects of intraoperative tumour-bed irradiation with low-energy X-rays (LEX-IORT). Translational Cancer Research.2014;3:3-17.
Fastner, G., Gaisberger, C., Kaiser, J., Scherer, P., Ciabattoni, A., Petoukhova, A., Sperk, E., Poortmans, P., Calvo, F.A., Sedlmayer, F., Cristina Leonardi, M., ESTRO IORT Task Force/ACROP recommendations for intraoperative radiation therapy with electrons (IOERT) in breast cancer, Radiotherapy and Oncology (2020), doi: https://doi.org/10.1016/j.radonc.2020.04.059
Veronesi U, Orecchia R, Luini A, Gatti G, Intra M, Zurrida S, et al. A preliminary report of intraoperative radiotherapy (IORT) in limited-stage breast cancers that are conservatively treated. European journal of cancer (Oxford, England : 1990). 2001;37:2178-83
Veronesi U, Orecchia R, Maisonneuve P, Viale G, Rotmensz N, Sangalli C, et al. Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial. The Lancet Oncology. 2013;14:1269-77.
Smith BD, Arthur DW, Buchholz TA, Haffty BG, Hahn CA, Hardenbergh PH, et al. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). International journal of radiation oncology, biology,physics. 2009;74:987-1001.
Correa C, Harris EE, Leonardi MC, Smith BD, Taghian AG, Thompson AM, et al. Accelerated Partial Breast Irradiation: Executive summary for the update of an ASTRO Evidence-Based Consensus Statement. Practical radiation oncology. 2017;7:73-9.
Polgar C, Van Limbergen E, Potter R, Kovacs G, Polo A, Lyczek J, et al. Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the Groupe Europeen de Curietherapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence (2009). Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology. 2010;94:264-73.
Leonardi MC, Maisonneuve P, Mastropasqua MG, Morra A, Lazzari R, Rotmensz N, et al. How do the ASTRO consensus statement guidelines for the application of accelerated partial breast irradiation fit intraoperative radiotherapy? A retrospective analysis of patients treated at the European Institute of Oncology. International journal of radiation oncology, biology, physics. 2012;83:806-13.
Leonardi MC, Maisonneuve P, Mastropasqua MG, Morra A, Lazzari R, Dell'Acqua V, et al. Accelerated partial breast irradiation with intraoperative electrons: using GEC ESTRO recommendations as guidance for patient selection. Radiotherapy and oncology: journal of the European Society for Therapeutic Radiology and Oncology. 2013;106:21-7.
Maluta S, Dall'Oglio S, Marciai N, Gabbani M, Franchini Z, Pietrarota P, et al. Accelerated partial breast irradiation using only intraoperative electron radiation therapy in early stage breast cancer. International journal of radiation oncology, biology, physics. 2012;84:e145-52.
Takanen S, Gambirasio A, Gritti G, Kalli M, Andreoli S, Fortunato M, et al. Breast cancer electron intraoperative radiotherapy: assessment of preoperative selection factors from a retrospective analysis of 758 patients and review of literature. Breast cancer research and treatment. 2017;165:261-71.
Ollila DW, Klauber-DeMore N, Tesche LJ, Kuzmiak CM, Pavic D, Goyal LK, et al. Feasibility of breast preserving therapy with single fraction in situ radiotherapy delivered intraoperatively. Annals of surgical oncology. 2007;14:660-9.
Martignano A, Menegotti L, Valentini A. Monte Carlo investigation of breast intraoperative radiation therapy with metal attenuator plates. Medical physics. 2007;34:4578-84.
