Radioterapia en cáncer de páncreas

DR. PALIZA RAVAZZANI ALDO. RADIOTERAPIA INEN LIMA PERU [email_address] Radioterapia en cáncer de Páncreas

CONTENIDO Generalidades Neoadyuvancia Adyuvancia Localmente avanzada Radioterapia IO Braquiterapia IMRT Tratamiento paliativo

Neoadyuvancia… Radioterapiaperu.com

Neoadyuvancia… ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Vento et al, World J Gastroenterol, 2007;13 (21): 2945-2951 NCCN Practice Guidelines, 2008 White et al. 2001 Annals of Surgical Oncology 8 (10): 758-765 Semin Radiat Oncol, 2005;15:226-234

Neoadyuvancia… ,[object Object],[object Object],[object Object],[object Object],Semin Radiat Oncol, 2005;15:226-234 Gastroenterol Clin N Am 36 (2007) 391-411 Radioterapiaperu.com

Survival Advantage of Combined Chemoradiotherapy Compared with Resection as the Initial Treatment of Patients with regional Pancreatic Adenocarcinoma ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Snady et al, Cancer 2000;89(2):314-327 68 pacientes LA no resecable + RT-FSP Con o sin resección 91 pacientes Enfermedad Resecable con o sin adyuvancia

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Snady et al, Cancer 2000;89(2):314-327

Snady et al, Cancer 2000;89(2):314-327 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Neoadyuvant Chemoradiation for Localized Adenocarcinoma of the pancreas ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],White et al. Annals of Surgical Oncology 2001 8 (10): 758-765

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Neoadyuvant Chemoradiation for Localized Adenocarcinoma of the pancreas White et al. Annals of Surgical Oncology 2001: 8 (10): 758-765 Resección > QTRT PR > QRT > Resecciòn LA > QRT >Resección postQx P 0.04

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Neoadyuvant Chemotherapy and Radiation for Patients with Locally Unresectable Pancreatic Adenocarcinoma: Feasibility, Efficacy and Survival. J Gastrointest Surg (2008) 12:91-100 Cáncer de páncreas Exploración Qx Resecable No resecable Pancreatectomía imagen TAC IRM USE No resecable Biopsia Adenocarcinoma Neoadyuvancia 3 ciclos RT (50.4Gy) Re-estadiaje Por imagen Resección 167 pts 78 pts 245 pts

[object Object],[object Object],[object Object],[object Object],La SV media para los Pacientes que recibieron Neoadyuvancia fue 533 días vs 192 que no recibieron P < 0.001 Neoadyuvant Chemotherapy and Radiation for Patients with Locally Unresectable Pancreatic Adenocarcinoma: Feasibility, Efficacy and Survival. J Gastrointest Surg (2008) 12:91-100

Neoadyuvancia BMC cancer 2007;7:41 J Am Coll Surg 2005;201:359-365, Estudio No. Pac. Dosis RT QT (mg/m2) SV (meses) SV (% años) Rec. Local Indice de Resec. R0 Breslin Et al 2001 132 45 o 50.4 Gy O 10 x 3 Gy IO 5-Fu o Tax o GMZ 21 1ª: 75 2ª: 40 5ª: 23 8/132 (6%) -na 88% Sasson Et al 2003 116 61 Neo 55 Ady 50.4 Gy 5-Fu/MMC o GMZ 18 todos 23 Neo 16 Ady na na -na 39% Na Na White et al 2005 193 45 + 5.4 Gy 5-Fu o GMZ 23 39 PR 20 LA 3ª: 37 %Res 5ª: 27% Res Na 70/193 (36%) 54/102 (53%) 16/91 (18%) 73% Na Na Cunha et al 2005 310 con LA 13 Qx 45 Gy Fx de 1.8 Gy 5Fu en infusion 650 mg/m2 +CDDP 11 meses en no operados 28 meses en Qx No Qx: 1a:47% 3 a: 5% Qx: 1a:84% 3 a: 37% na 13/310 (4%) 84.6% Brown et al 2007 13 50.4 Gy en –fx de 1.8 Gy 5Fu, GMZ, capecitabina, bevacizumab 69% 24 meses na 5/13 Na 85%

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Adyuvancia… Radioterapiaperu.com

Adyuvancia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Gunderson. 2007. Clinical Radiation Oncology

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Adyuvant Radiotherapy and 5-Fu after curative Resection of cancer of the pancreas and periampullar region RTE + Infusión continua de 5Fu (104 pacientes) (40 Gy/20 Fx) 2 Brazos Observación (103 pacientes) Ann Surg 1999;230(6)776-782. P= 0.208

[object Object],[object Object],[object Object],[object Object],The Lancet 2001;358:1576-85 . 548 pacientes 541 con adenoca de pancreas Resecados 69 Observa- ción 70 QT/RT 74 QT 72 QT/RT--QT 68 Aleatorizados QT/RT 35 No QT/RT 33 QT/RT 188 Aleatorizados QT solamente 96 No QT 92 QT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],/ RT / RT QT/RT No QT/RT QT No QT No QT 33 pts QT 64 pts No QT/RT 34 pts QT/RT 18 pts

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Neoptolemos et al, N Engl J Med 2004; 350:1200-10 A Randomized Trial of Chemoradiotherapy and Chemotherapy After resection of pancreatic cancer 289 pts con adenoca De páncreas + resección 69 Observ. 73 QT/RT 75 QT 72 QT/RT-- QT Comparación del tratamiento No QT/RT vs QT/RT 144 vs 145 No QT vs QT 142 vs 147

[object Object],[object Object],[object Object],[object Object],A Randomized Trial of Chemoradiotherapy and Chemotherapy After resection of pancreatic cancer Neoptolemos et al, N Engl J Med 2004; 350:1200-10

A Randomized Trial of Chemoradiotherapy and Chemotherapy After resection of pancreatic cancer No QT/RT SV media 17.9 meses SV QT/RT SV media 15.9 meses meses HR con QT/RT 1.28 P: 0.05 SV 2 años: 29% SV 5 años: 10% Neoptolemos et al, N Engl J Med 2004; 350:1200-10 HR sin QT 0.71 P: 0.009 SV 2 años: 40% SV 5 años: 21 QT SV 20.1 meses No QT SV 15.5 meses meses SV

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],A Randomized Trial of Chemoradiotherapy and Chemotherapy After resection of pancreatic cancer Neoptolemos et al, N Engl J Med 2004; 350:1200-10

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Fluorouracil vs Gemcitabine Chemotherapy Before and After Fluorouracil-Based Chemoradiation Following Resection of Pancreatic Adenocarcinoma: A Randomized Controlled Trial J Clin Oncol 2006;24(18S):4007, JAMA, 2008; 299(9):1019-1026 ,[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],JAMA, 2008; 299(9):1019-1026 P: 0.09 HR: 0.89 Fluorouracil vs Gemcitabine Chemotherapy Before and After Fluorouracil-Based Chemoradiation Following Resection of Pancreatic Adenocarcinoma: A Randomized Controlled Trial J Clin Oncol 2006;24(18S):4007,

Adyuvancia ,[object Object],[object Object],[object Object],[object Object],[object Object]

Cáncer de páncreas localmente avanzado … Radioterapiaperu.com

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],The Oncologist 2006;11:612-623 QT sola Qx paliativa

Tratamiento en Ca de páncreas localmente avanzado ,[object Object],[object Object],[object Object]

Therapy of locally unresectable Pancreatic Carcinoma: A Randomized comparison of High dose (6000 Rads) Radiation alone, Moderate Dose Radiation (4000 Rads + 5 Fu), and High Dose Radiation + 5 Fu ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Cancer, 1981;1705-1710 6000 cGy 25 pts 4000 cGy + 5 Fu 83 pts 6000 cGy + 5Fu 86 pts

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Therapy of locally unresectable Pancreatic Carcinoma: A Randomized comparison of High dose (6000 Rads) Radiation alone, Moderate Dose Radiation (4000 Rads + 5 Fu), and High Dose Radiation + 5 Fu Cancer, 1981;1705-1710 Tratamiento No pac. Tiempo medio a progresión 4000 cGy + 5-Fu 28 30.4 6000 cGy + 5-Fu 31 33 6000 c Gy 25 12.6 P 0.14 Supervivencia: La SV en el grupo de 6000 cGy + 5Fu fue igeramente mayor (P 0.19) Conclusión: AGREGAR 5 FU AL ESQUEMA DE RT MEJORA SIGNIFICATIVAMENTE LA SV EN COMPARACIÓN CON RT SOLA

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Is the Therapeutic index Better with Gemcitabine-based chemorradiation Than with 5-Fluorouacil-based chemorradiation in Locally Advance Pancreatic Cancer? Int. J. Radiation Oncology Biol. Phys, 2002;52:1293-1302

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Is the Therapeutic index Better with Gemcitabine-based chemorradiation Than with 5-Fluorouacil-based chemorradiation in Locally Advance Pancreatic Cancer? Int. J. Radiation Oncology Biol. Phys, 2002;52:1293-1302

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],J Clin Oncol 2007;25:326-331

[object Object],[object Object],[object Object],[object Object],[object Object],J Clin Oncol 2007;25:326-331 CRT (72 PTS) 56% QT (56 pts) 44% A B

J Clin Oncol 2007;25:326-331 Supervivencia global: Grupo A: 15 meses Grupo B: 11.7 meses P: 0.0009 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Localmente avanzado The Oncologist 2006;11:612-623 JCO 2004;22(14S) 4105, Proc Am Soc Clin Oncol 2000;19:265 Int J Gastrointest Cancer 2003;34:107-116 Gastrointestinal Cancer Symposium, 2004;22-24 IJROBP 2003; 57:98-104 IJROBP 2002; 54:137-141 Estudio Regimen No. de Pacientes SV media (meses) SV a 1 año Moore 2004 RT + GMZ semanal 28 7.9 31.1% Epelbaum 2000 RT + GMZ Semanal 20 12 - Blackstock 2003 RT + GMZ dos Veces x semana 38 7.8-13.7 - McGinn 2004 RT hipofraccionada + GMZ dosis completa 41 11.6 - Haddock 2004 RT + GMZ + CDDP 20 8.8 29% Safran 2002 RT + Paclitaxel 109 11.2 43%

Tratamiento con QT/RT en enfermedad localmente avanzada ,[object Object],[object Object],[object Object]

Radioterapia intraoperatotria … Radioterapiaperu.com

Radioterapia intraoperatoria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

External Beam vs Intraoperative and External Beam Irradiation for locally Advanced Pancreatic Cancer ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Cancer 1988; 61:1110-1116 RESULTADOS: GRUPO 1 GRUPO 2 Falla local 88 (72%) 6 (16%) Control local 48% (1 año) 82% (1 año) P: 0.001 20 % (2 años) 66% (2 años) SV media 12.6 meses 13.4 meses P: 0.25 Tumores en la cabeza del páncreas: Menor índice de falla local P 0.001

Radioterapia intraoperatoria ,[object Object],[object Object],[object Object],[object Object]

Braquiterapia… Radioterapiaperu.com

Braquiterapia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Long-Term Results of Combined Modality Treatment with I-125 Implantation for carcionma Of the Pancreas. Mohiuddin et al. International Journal of Radiation Oncology Biol Phys 1992;23:305-311 Temprana: Pancreatitis Pseudoquistes Abscesos Colangitis Nausea Vómito Pérdida de peso Tardía: STD Reflujo biliar ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],P: < 0.05

Journal of Surgical Oncology 61:300-305 (1996)

Braquiterapia ,[object Object],[object Object],[object Object],[object Object]

IMRT… ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Intensity-Modulated Radiotherapy (IMRT) and Concurrent Capecitabine For Pancreatic Cancer Int J Radiation Oncology Biol Phys, 2004;59:454-459 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Phase II Study To Assess The Efficacy Of Conventionally Fractionated Radiotherapy Followed By A Stereotactic Radiosurgery Boost In Patients With Locally Advanced Pancreatic Cancer Int J Radiation Oncology Biol Phys, 2005;63:2:320-323 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Conclusiones IMRT ,[object Object],[object Object],[object Object],[object Object]

Tratamiento paliativo… Radioterapiaperu.com

Enfermedad metastásica Tratamiento paliativo ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Gunderson et al, 2007. Clinical Radiation Oncology Mejor soporte médico

Radioterapia en cáncer de páncreas

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