bronqui academia 2012.ppt [modo de compatibilidad] · hemoptisis fatales 64% mejoraro la disnea...

Institut Català d’OncologiaServei d’Oncologia Radioteràpica – Hospital Duran i Reynals.

BRAQUITERAPIA ENDOBRONQUIAL

Joan Pera, Cristina Gutiérrez, Antoni Rosell, Juan Carlos Menéndez, Francisco Pino,

Evelyn MartínezServei Oncologia Radioteràpica ICO-Ferràn Guedea.Servei de Pneumologia HUB-Frederic Manresa.Servei de Física Mèdica i Protecció Radiològica-Cristina Picón

SOCIETAT CATALANO-BALEAR ONCOLOGIADimarts, 17 d’abril del 2012


Braquiterapia en el cáncer de pulmón


BRAQUITERAPIA ENDOBRONQUIAL

REVISIÓN DE LA LITERATURA


Nº Estadio DosisGy

Frac 100%mm

Resp%

LC(Años)

OSaños

toxicidad

Perol1997

19 N0, <1cmOculto ct

7 3 - 5 10 83 (1)75 %

1a 78%2a 58%

3/18 ; 16,5%

Peiffert2000

25 t1n0m0 6 5 10 100 (2)90%

no

Marsiglia2000

34 T1,2,4n0 5 6 5-10 94 (2) :85%(3): 73%

2 años78%

no

Hennequin2007

106 N0,<1 cmOculto ct

5 7

6 5-15 59,4 Hi+ 21,8

(2):60,3%(5):51,6%

2 47,4%5 24%

4,7% mortales

Guilcher2011

226 T1s,1 y 2 567

654 - 5

10 93,6 DFS(2): 68%(5): 50%

2 57%5 29%45 muertesintercurrentes

6%

Braquiterapia bronquial -radical


Estudios de bt exclusiva bronquioBraquiterapia bronquial -radical



• Compara rdt extr + bt / bt en tumores ocultos.

40 Gy Rdt ext

46 Gy Rdt extfuwa


RDTE Externa / RDT Ext + Braqui. (Avanzados)Braquiterapia en el cáncer de pulmón (Radical)

Huber RM, Fischer R, Hautmann H, Pollinger B, Haussinger K, Wendt T. Does additional brachytherapy improve the effect of external irradiation? A prospective, randomized study in central

lung tumors. International Journal of Radiation Oncology, Biology, Physics 1997;38(3):533-40.

Study

Methods Open randomized controlled trial N: 98

ParticipantsPatients with inoperable advanced non small cell lung cancer, located in the trachea, mainsteam or lobar bronchi, with not further concurrent tumor treatment and Karnofsky performance status greater than 50%.

Interventions 42 Group 1, and were treated with external radiationdose of 50- 60 Gy;

56 Group 2, received external radiation dose of 50 -60Gy followed by an additional dose 4,8 Gy x 2 fr (at 10 mm depth) BT one week before, and three weeks aftercompletion of EBRT .

Outcomes Survival time was considered the principal end point of the study; assessment of local control, time until observed local recurrence and adverse effects were considered as secondary outcomes.


RDTE Externa / RDT Ext + Braqui.

OS meses 6 12

Rdt ext 50 % 19 %

RDT + BT 48 % 25 %

P:0,42

Hemoptisis 6 (15,3 %) / 11 (20,8%) p:0,22



Braquiterapia paliativa

- Braquiterapia.- RDT externa <<>> Braquiterapia (Stout)- RDT externa + Braquiterapia ( Sur , Lajendijk )


Estudios de braquiterapia bronquial paliativa

Nº Dosis Gy

F 100%mm

toxicidad Resultados

Hatlevoll19991988-96

45 10-24 6-15 Gy

1- 3s

10 12/45Hemoptisisfatales

64% mejoraro la disneaSupervivencia media 13 semanas

Huber 1995 44

49

15,2

14,4

3,8Gyx 4s

7,2Gyx 2s

10 31,8%

17,2%

Sup 6 meses 29,5% 1 año 11,4%

20,4% 20,4%

Kelly 20001988-1997

175 30 15 Gy

1- 3 s

6 9% hempo2 necrosis

32% Gran meoria Sup media 6 meses.34% leve mejoria17% No cambios10% empeoran

Escobar 2004 81 20 5 Gy

4 s

5-10 1 fístula Mejoria 84,5%RC: 56,8%Rp: 40,74%

Skowronek 20091999-2004

624 22,5

10

7,5 Gyx3s

1 s

10 Mejoria 88,4% superv media 3,71 meses; al año 34,8%RC:

Hauswald 20101987-2005

41 15 5Gy x3S 10 3 necrosis1 hemorragia2 fístulas

Suprv año 18%, a los 2 años 7%, sup media 6,7 meses.Mejoria excelente 12%, buena 46%


• Paliativo : Externa/Braquiterapia.


99 participants. randomization.

Participants99 inoperable NSCLC were prospectively randomisedto receive EB or EBRT.

Interventions 49 received a single exposure of 15 Gy EB

50 received megavoltage EBRT, 30 Gy.

Outcomes Mortality, adverse events. Clinician and patient assessments for nine key symptoms(cough, haemoptysis, breathlessness, chest pain, dysphagia,anorexia, tiredness, nausea and hoarseness). Quality of life questionnaires.

•Stout R, Barber P, Burt P, Hopwood P, Swindell R, Hodgetts J, et al. Clinical and quality of life outcomes in the first United Kingdom randomized trial of endobronchial brachytherapy (intraluminal radiotherapy) vs. external beam radiotherapy in the palliative treatment of inoperable non-small cell lung cancer. Radiotherapy and Oncology 2000;56(3):323-7.


Radiother Oncol. 2000 Sep;56(3):323-7.Clinical and quality of life outcomes in the first United Kingdom randomized trial of endobronchial brachytherapy

(intraluminal radiotherapy) vs. external beam radiotherapy in the palliative treatment of inoperable non-small cell lung cancer.

Stout R, Barber P, Burt P, Hopwood P, Swindell R, Hodgetts J, Lomax L.

SourceDepartment of Clinical Oncology, The Christie Hospital NHS Trust, Wilmslow Road, Withington, Manchester M20 4BX, UK.

Abstract

BACKGROUND AND PURPOSE: A randomized controlled trial was designed to evaluate the clinical and quality of life (QL) outcomes of patients receiving

endobronchial brachytherapy (EBT) or external beam radiotherapy (XRT) as a primary palliative treatment in advanced lung cancer.

MATERIALS AND METHODS: Ninety-nine patients presenting de novo with lung cancer were randomized to receive EBT or XRT. Eleven key symptoms or

clinical signs were assessed by clinicians and patient ratings using self-assessment questionnaires were obtained at the same time. The primary endpoints were a comparison of EBT and XRT for symptom relief and acute and late side-effects (palliation) and

their effect on patients' functional status and patient-rated QL outcomes. A secondary objective was a comparison of clinician assessments with patient self-reported symptoms.

RESULTS: Both treatments produced good levels of symptom relief. They were better for XRT at the expense of more acute morbidity. Lateside-effects were similar. The functional status of patients was well maintained and changed similarly with time in both groups.

XRT gave a better duration of palliation. Twenty-eight percent of XRT patients required EBT (at a median time of 304 days) whereas 51% of EBT patients subsequently had XRT (at a median of 125 days). There was a significant modest gain in median

survival with initial XRT (287 vs. 250 days). When clinician and patient assessments were compared, doctors were found to underestimate the severity of breathlessness, anorexia, tiredness and nausea.

CONCLUSIONS: Fractionated XRT is preferred to EBT as an initial treatment in better performance patients because it provides better

overall and more sustained palliation with fewer retreatments and a modest gain in survival time. QL assessment is required in the evaluation of palliative treatments because clinicians frequently underestimate the incidence and severity of key

symptoms.


Paliativo : Externa/Braquiterapia.

Supervaños

1 2

Rdtext 38% 10%

Bt 22% 2%


Paliativo : Externa/externa +Braquiterapia.

65 pacientes estadio III.

RDT ext 30-40 Gy A: 2 x 6 Gy Bt HDR.

B: 20 Gy a 2 Gy RDText.

Resultados: S libre síntomas A: 77 días / B: 129 días p: 0, 009.

Supervivencia al año A: 29,7% / B: 29,4%.

Conclusions: In our experience EBRT boost provided longer symptom palliation than BT boost in patients with NSCLC treated with radiotherapy for palliation



• Langendijk H, de Jong J, Tjwa M, Muller M, ten Velde G, Aaronson N, et al. External irradiation versus external irradiation plus endobronchial brachytherapy in inoperable non-small cell lung cancer: a prospective randomized study.

• Radiotherapy and Oncology 2001;58(3):257-68.

• Open randomized controlled trial that included 95 participants..47 were randomized to receive EBRT alone 30 – 60 Gy

48 to EBRT and EB. ( 2 x 7 Gy a 10mm )• Survival, respiratory symptoms (dyspnea), changes in quality of life (QoL), re-expansion of atelectasis, complications

were assessed.

• Inclusion criteria:Biopsy proven NSCLC, stage I, II, IIIa or IIIb diseaseaccording to the UICC 1992 [1], endobronchial tumour inthe proximal main bronchus or lobar bronchus,

• For external irradiation, two fractionationschedules were allowed, i.e. a radical fractionation schedule(60 Gy) or a palliative fractionation schedule (30 Gy).

• RDTE Externa / RDT Ext + Braqui.



Rdt ext Rdt ext + BtDisnea 37% 46% (P . 0:29).

Tumores centrales

Tos 38% 24%Hemoptisis 13% 15%Superv (meses) 8,5 7



Laser/laser + BT

15 Laser

14 laser + bt (15 Gy, 5 Gy/f 100% 5mm)

Respuestas (Tras laser):

mejoría disnea en el 67% de los pacientes

Tos 48%

Duración de la respuesta : 2,8 meses/8,5 meses

P<0,05

Sup media : 9,2 meses.

Coste: 2834 Euros/1446 Euros

No aumento de complicaciones.


• Conclusiones de la braquiterapia bronquial.

- La Braquiterapia radical es curativa en tumores pequeños. Faltan estudios que comparen BT con la combinación de RDT ext y BT.

- La BT endobronquial no parece que mejore los resultados de la RDT externa.

- Solo tendría aplicación en tumores endobronquiales centrales (bronquios principales), donde la asociación de RDText + Bt, abre las atelectasias y mejora la disnea.

- La asociación de laser y BT es segura y prolonga el efecto paliativo del tratamiento.


BRAQUITERAPIA ENDOBRONQUIAL INTENCION CURATIVA

INDICACIONES

• EXCLUSIVA : TUMORES INTRABRONQUIALES INOPERABLES Y NO IRRADIABLES.

• SOBREDOSIS: COMPLEMENTARIA A LA RTE

• RESCATE: RECAIDAS ENDOBRONQUIALES EXCLUSIVAS POST RTE


BRAQUITERAPIA ENDOBRONQUIAL INTENCION CURATIVA

DOSIS

• EXCLUSIVA : 6 SESIONES DE 5Gy SEPARADAS 1 SEMANA

• SOBREDOSIS: DOSIS EQUIVALENTES A 70-80 Gy SUMANDO RTE+BRA

• RESCATE: 3-4 SESIONES DE 5Gy SEPARADAS 1 SEMANA


BRAQUITERAPIA ENDOBRONQUIAL INTENCION PALIATIVA

INDICACIONES

• METASTASIS ENDOBRONQUIALES

• RECIDIVAS POST RTE

• OBSTRUCCIONES BROQUIALES INTRINSECAS SINTOMÁTICAS


BRAQUITERAPIA ENDOBRONQUIAL INTENCION PALIATIVA

DOSIS

• 2-3 SESIONES DE 7-8 GY

• DOSIS EQUIVALENTES A 30-40 Gy RTE


BRAQUITERAPIA ENDOBRONQUIALCONTRAINDICACIONES

• GRAN COMPONENTE EXTRABRONQUIAL

• GRANDES ADENOPATIAS

• COMPRESION BRONQUIAL EXTRINSECA

• LESIONES QUE AFECTEN GRANDES VASOS

• LESIONES ULCERADAS O NECROSIS DE LA PARED BRONQUIAL

• LESIONES A LAS QUE NO LLEGUE EL CATETER PORTAFUENTES

• CONTRAINDICACIONES A LA BRONCOSCOPIA


TÉCNICA


•Flexible bronchoscopy and insertion of the brachytherapy applicator is performed with the patient in a sitting or supine position.• The bronchoscope is usually advanced through the nose or mouth.• Local anaesthesia to the nasal cavity and the nasopharynx is given before inserting the bronchoscope and then continuously via the dedicated channel of the bronchoscope.


•The distance to the proximal and distal edges of the macroscopic tumour is measured by moving the bronchoscope. •It can also be accurately documented on two anterior-posterior X-rays in the treatment (supine) position with the tip of the bronchoscope at the distal and proximal end of the GTV.


GTVCTV

LUZ BRONQUIAL

PTL

PTV

P

PRESCRIPCION DE LA DOSISPunto prescripcion. Longitud planificacion


Dosimetry

•Dose per fraction 5Gy at 5-10 mm from the axis of the source.•Treatment interval: one week•Total dose of 25-30Gy


The Reference Volume Length (RVL) is as the length of the 90%-isodose at the

reference depth of 5 mm.

Dose distribution and reporting for centred (B1) and non-centered (B2) applicators.


www.iconcologia.netInstitut Català d’Oncologia

ICO l’HospitaletHospital Duran i ReynalsGran Via de l’Hospitalet, 199-20308907 l’Hospitalet de Llobregat

ICO BadalonaHospital Germans Trias i PujolCtra. del Canyet s/n08916 Badalona

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bronqui academia 2012.ppt [modo de compatibilidad] · hemoptisis fatales 64% mejoraro la disnea...

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