VLOGA RADIOTERAPIJE PRI RAKU JAJČNIKOV v Manj a Kobav, Barbara Segedin IZ SMERNIC. 2015 g I 5C g QC N O -j 0 CQ S 1 QC CQ O S £ cl CQ O O O Snema nakfwfwa brine/ rabn^čiim. m oboden m t prtrurnm prttinaihn saranni ntan 21 OBSEVANJE • km paliatlvno zdravljenj« v primeru metastatske bolezni z namenom lajšanja simptomov (krvavitev bolečina, dispneje, možganski zasevkl, Ipd./ • kot »reševalno obsevanje« v primeru lokaliarane-ga ostanka bolezni: * po primarnem zdravljenju s kirurgijo In kemoterapijo • ob lokallzlranl ponovitvi bolezni, ko kirurško zdravljenje ni možno ■ po nepopolni sekundami dtoredukdji 102 2015 VS 2020 2015 2020 2020 01 01 UKCMB Skupaj 35 25 6 medenica (vključena 17 10 1 krvavitev iz nožnice) bezgavke nad prepono 5 2 1 bezgavke pod prepono 5 1 0 kožni zasevki 3 0 1 skelet 3 8 2 možganski zasevki 2 2 1 trebuh 0 2 0 103 Paliativno obsevanje 17/25 (+ UKC MB 6/6) ► 1-10 frakcij ► TD 8 - 30 Gy Obsevanje z veliko dozo 5/25 >► 12-25 frakcij ► TD 36 - 50 Gy SBRT / SRS 3 / 25 ► 1-5 frakcij ► Velike doze na frakcijo (22,5 Gy, 16 Gy, 8 Gy) in TD PALIATIVNO OBSEVANJE >► Veliko izkušenj, številne raziskave >► Bolnice z napredovalo boleznijo >► namen: lajšanje simptomov (bolečina, krvavitev iz nožnice, težko dihanje, simptomi zaradi možganskih zasevkov, pritiska povečanih bezgavk) ► Malo število obsevanj, majhne doze ► Choan, 2006: CR zmanjšanje bolečine 65 %, zaustavitev krvavitve 88 % (CR + PR 100 %) ► Jiang, 2018: CR + PR: zmanjšanje bolečine 87 % (skeletne le 75 %), zaustavitev krvavitve 93 % PALIATIVNO OBSEVANJE 106 OBSEVANJE Z VELIKO DOZO ► Večje število frakcij, velika skupna doza ► Različno poimenovanje glede na to, kdaj se odločimo za obsevanje / namen in tehnika obsevanja enaki ► Reševalno - konsolidacij sko - pooperativno - radikalno ► Lokalizirana bolezen Lokaliziran ostanek po primarnem zdravljenju Lokalizirana inoperabilna ponovitev Lokalizirana ponovitev (z nepopolno citoredukcijo) Rl, R2 ► Ob operaciji označba sumljivih mest s klipi (naleganje na žile, obraščanje sečevoda) ► Namen: zmanjšanje tumorske formacije (delni ali popolni odgovor), izboljšanje lokalne kontrole bolezni OBSEVANJE Z VELIKO DOZO Lokaliziran recidiv, 60 - 62 % citoredukcija pred RT TD 45 - 60 Gy (Yahara, 2013, Brown, 2013) Izboljšanje lokalne kontrole (LC 90 %), daljši čas do progresa (> 1 leto), ponovne KT, boljši OS Večina novih ponovitev izven RT polja Smart, 2019: 10 % po 5-ih letih brez ponovitve bolezni Author Year Stage Study design N Comments o o ñ ® a 0) 5 c ü> E o Î O C/) 'Z D TJ C ra v. ra N •ra 0 ra CO 1 t/5 o Albuquerque et al. 2016 Nodal, pelvis (54) Retroperitoneal Retrospective IFRT median dose: 27 50 Gy conventional fractionation Choi et al. (55) 2017 Nodal and extranodal 3D-CRT disease 44 Chang et al. (56) 2018 Nodal and extranodal Prospective phase II; IFRT-IMRT, - disease 3D-CRT or brachytherapy Komura ei al. (57) 2019 Nodal or extranodal Retrospective 3D-CRT recurrence 24 Smart eí al. (58) 2019 Peritoneal, nodal, Retrospective IFRT 3D-CRT 40 vaginal 5-year LRFS: 70%; 5-year DFS: 33% The 1- and 2-year in-field LC rates were 66.0% and 55.0%, respectively. BED 2:50 Gy showed better outcomes Overall and CRRs were 85.7% and 50%, respectively. The 2-year PFS rate was 39.3%. The 3-year LC and OS rates were 84.4% and 55.8%, respectively In-field overall response of 58.3%, median regression was 40.2%. The 1-year survival and local PFS rates after RT were 66.7% and 45.8%, respectively At 3 years, DFS and OS were 18% and 80%, respectively. Non-serous histology and platinum sensitivity were associated with lower relapse risk log o o SBRTISRS Prve bolnice z rakom jajčnika na OI 2020 Solitarni zasevek Lega, velikost, v katerem organu, priležne strukture dobro omejena lezija, PS po WHO 3 bolnice (1 bolnica s solitarnim zasevkom v CŽS, 2 bolnici s solitarnim zasevkom v jetrih) Author Year Study design N Comments Iftode et al. (68) 2018 Retrospective SBRT (lymph nodes, liver, lung) Lazzari et at. (69) 2018 Retrospective SBRT 26 patients; 44 lesions 1-year PFS: 69.3%, 1-year OS: 100%; 2-year PFS: 38%, 2-year OS: 92.7%; 5-year PFS: 19%, 5-year OS: 61.7% 82 patients; 156 lesions Macchia et al. (70) 2020 Retrospective, multicenter 261 patients; 449 study (MITO RT-01) lesions SBRT/SRS Median systemic treatment-free interval after SBRT: 7.4 months, 2-year local PFS: 68%, PFS: 18%, OS: 71%. CRR: 65.2%, PRR: 23.8%, SD: 7.4%, PD: 3.6%; 2-year LC: 81.9%, ORR: 89%, CB: 96.4%, AT: 20.7%, LT: 6.1%, 2-year late TFS: 95.1% Flores-Balcazar and Urias-Arce. RT in women with epithelial OC 110 PRIMER SRS ► Solitarni zasevek v možganih, premer 11,5 mm, inoperabilen ► 06/20 SRS 1 x 22,5 Gy >► 10/20 regres lezije z okolno levkoplakijo >► 02/21 radionekroza, brez ponovitve ali ostanka m PRIMER SBRT1 >► 02/20 novo nastal solitarni zasevek v jetrih, fokalna lezija velikosti 22 x 28 mm ► 06/20 vstavitev zlatih markerjev v jetra, SBRT 3x16 Gy, prehodna prekinitev Olapariba ► 09/20 CR, 02/21 CR 112 PRIMER SBRT 2 \ J 1 ► 09/18 ponovitev bolezni (jetra 7,5 x 9 cm, bezgavki) ► KT II. reda, PR, vzdrževalno Olaparib ► progres lezije v jetrih ► 01/20 vstavitev zlatih markerjev v jetra, SBRT 5x8 Gy, prehodna prekinitev Olapariba ► 05/20 regres, 10/20 počasen progres, 01/21 KT III. reda 113 PRIHODNOST: PARP INHIBITORJI ALI IMUNOTERAPIJA SOČASNA RT Raziskave v teku QC CQ O S TABLE 3 1 Select cogarig dries! irate of radatkr conbratiors Description Phase Disease site NCT number Agent(s) Sponsor Poly(ADP-nbose) polymerase + radiation Claparb and Radiotherapy in heed and neck cancer 1 Squamous eel carcnoma of the laryrx stage !-■ NCTO229666 Obparib 25-300 mg BD The Netherlands Cancer hsutute R-ase 1 study of olaparb corrtaned wth asptetr-besed chemoradiotherapy to trea! localfy advanced haad and neck cancer (OPCA 2) 1 High-nsk locally advanced HNSOC NCTOS308072 Olaperib 80-200 mg BD Ceptatn 3S mg/WQ week Cancer Research UK □apart and radiotherapy in inoperable breast cancer 1 Breast cancer or local rea/rence of breast cancer, which is naperable or/and metastatic, ndudng rftanmatDry breast cancer NCT0B227082 Olaperib 25-400 mg BD The Netherlands Cancer hslitute Vcipanb with or without raciatcr therapy; carboplatr. and padrtaaoel r patients wth stage ■ rrar-small cell ling cancer that cannot be removed byaxgery 1/1 Unresectable stage OAAB. non-smal eel lung cancer NCTDI396385 Ann I Carbcpiatn. Padrtaxel Am II Carbcplalr. Paditamel. Vetoarb NCI; Southwest Oncology Grotp Velparib and combination dierrctherapy n treat ng patient with locally advanced rectal cancer II Locally advanced adenocarcinoma of the rectun, Stage IIM NCT029212S6 Am 1 (mTOLFOXa capecitabne) Am II frnFOLFOXB. capecitabre. veiperibj NCI; NRG Oncology Immunotherapy + radiation FLT3 ligand mmunotherapy and stereotactic radotherapy for advanced non-snail ceJ lung cancer II Stage IIL'V non-smal eel Uig cancer not amenable to aratrve therapy NCTQG83926B FLT3 Igand therapy (COX-301) with SBRT Abert Einstein College of Wedidne, Inc. Checkport blockade immunotherapy ccrrbined wth stereotactic body radiotherapy in advanced metastatic disease II Metastatic cancer «wth at least one lesion amenable to SBRT NCTQCaOf65 Checkpoint blockade mmunotherapies (arti-CTLA-d and anfc-PD- I/PO-L1 antibodes) wth SORT University of California. San Diego ProstAtak» Immuiolherapy with standard radiation therapy for localized prostate cancer III Localized prostate cancer meeting the NCCN catena of rternediale risk or patients havng only one NCCN high-risk feature NCT01A36968 Am I ProstAtak^AdV-tki + valacydovr Am II ^laoebo + valacyclovir Advartagene Inc. Ipiinmab and stereotactc body radotherspy (SBRT)in advanced sdid tumors l/l Metastatic cancer wth at Iee3t one metastatic or primary lesion in the Wer. lung, or adrenal gbnd NCT02239900 pLmumeb with SBRT M.D Anderson Cancer Center; aristol-Myers Sqjbb Pembrdia/nab and chemoradiation treatment for advanced oerweal cancer II Locally advanced cervical cancer stage Bf with lymph nodes or IB2-IVA NCTDC635360 Am I Csplatr-besed chemoradiation with oonsotdative pembrdizumab x 3 cydes Am II Chemoradiation with oonourrent Pembroizumab x 3 cydes University of Vrginta; Merck Sharp &Dohme Corp Frorters in Oncology | www.frcr1iersri.crg 9 August2017 | \fa)ime7 | Ancle 177 66 PRIHODNOST: WART >► Ponovno obsevanje celega trebuha, medenice: abdominalna kopel v sklopu adjuvantnega zdravljenja >► Z novimi tehnikami obsevanja, z nižjimi dozami na ledvice, jetra, kostni mozeg v ► Študije faze I, II: sprejemljiva toksičnost? dobrobit adjuvantnega obsevanja? ► OVAR-IMRT-02, prospektivna študija faze II, Arians, 2019 115