BEPERKEN VAN DE BESTRALING TOT EENZIJDIGE HALS MIDDELS SPECT-CT

Transcription

1 BEPERKEN VAN DE BESTRALING TOT EENZIJDIGE HALS MIDDELS SPECT-CT ONCOLOGIE IN PERSPECTIEF: (OVER)LEVEN AL-MAMGANI, MD, PHD RADIOTHERAPEUT-ONCOLOOG

2 WAAROM BILATERAAL

3 WAAROM BILATERAAL

4 BACKGROUND BILATERALE BESTRALING VAN DE HALS IN HOOFDHALSTUMROEN Rich lymphatic supply, also contralateral drainage. Occult nodal metastasis? also Contralateral? of all HNSCC will be treated bilaterally. Only small tumors of the tonsil and the larynx are treaed unilaterally. In the NKI/AVL, only 6% are treated to one side of the neck.

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8 ELECTIVE LEVELS IN HNSCC Subsite N0 N= Oral cavity I-III I-V Oropharynx I-IV I-V and RP Hypopharynx II-IV I-V and VI Larynx II-IV I-V and VI

9 BACKGROUND BILATERALE BESTRALING VAN DE HALS IN HOOFDHALSTUMROEN Rich lymphatic supply, also contralateral drainage. Occult nodal metastasis? also Contralateral? of all HNSCC will be treated bilaterally. Only small tumors of the tonsil and the larynx are treaed unilaterally. In the NKI/AVL, only 6% are treated to one side of the neck. Is this really necessary?

10 Current

11 REDUCING TREATED VOLUMES Current Future

12 WHY FROM BILATERAL TO UNILATERAL RT Sparen van omringende organen: Speekselklieren Slikspieren Kauwspieren Kaak Larynx Schildklier 12

13 T1N1 HPC (46 GY BOTH SIDES OF THE NECK AND BOOST 70 GY TO THE PT AND INVOLVED NODE)

14 T1N1 HPC (46 GY BOTH SIDES OF THE NECK AND BOOST 70 GY TO THE PT AND INVOLVED NODE) OAR Spinal cord Parotid gland, R (mean) Parotid gland, L (mean) SMG, R (mean) SMG, L (mean) Constrictor M (mean) Thyroid gland (mean) Dose 49.4 Gy 29.5 Gy 15.3 Gy 71.1 Gy 40.0 Gy 57.7 Gy 48.0 Gy

15 T2N1 LC (46 GY BOTH SIDES OF THE NECK AND BOOST 70 GY TO THE PT AND INVOLVED NODE)

16 T2N1 LC (46 GY BOTH SIDES OF THE NECK AND BOOST 70 GY TO THE PT AND INVOLVED NODE) OAR Spinal cord Parotid gland, R (mean) Parotid gland, L (mean) SMG, R (mean) SMG, L (mean) Constrictor M (mean) Thyroid gland (mean) Dose 47.1 Gy 46.8 Gy 17.9 Gy 71.1 Gy 40.0 Gy 58.9 Gy 46.6 Gy

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18 Current Future 18

19 HOW TO ADDRESS? Review of literature Tools to identify lymphatic drainage SUSPECT study Non-invasive accurate

20 INCIDENCE OF CONTRALATERAL RF (CRF) IN LATERALIZED OPC

21 PREDICTIVE FACTORS FOR CRF p-value T-stage N-stage No nodes (1 vs. more) SP involvement Midline involvement P=0.345 P=0.092 P=0.106 P=0.178 P=0.002

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23 INCIDENCE OF CONTRALATERAL RF (CRF) IN LATERALIZED OPC (O 'SULLIVAN) 16% 20% 6%

24 INCIDENCE OF CONTRALATERAL RF (CRF) IN LATERALIZED OPC (O 'SULLIVAN) No patients 228 Toronto O Sullivan FU time T-stage N-stage T subsite 7 Y All All All crf 3/37 (8%) 4/46 (9%) RT technique 2D/3D LC 77% 0% RC 81% Contralateral RF 3.5%

25 90 patients with T1-3N0 included SN was detected in all patients. 22% of the whole group showed occult metastasis in the removed SN 2/3 of all positive SNL were located at level II.

26 1 NUMBER OF PATIENTS (90) SN number No SN founded micromets macromets Total SN+ SN1 90 (100%) (15%) SN2 50 (55%) (10%) SN3 19 (21%) (5.2%) CL SN* 16 (17%) (6%, 1% whole group)

27 1 NUMBER OF PATIENTS (90) SN number No SN founded micromets macromets Total SN+ SN1 90 (100%) (15%) SN2 50 (55%) (10%) SN3 19 (21%) (5.2%) CL SN 16 (17%) (6%, 1% whole group) Number of harvested SN decreased by distance from primary tumor location and intensity node Number of positive SN decrease also by distance from the primary tumor location and intensity node

28 SN MAPPING USING SPECT (SUSPECT) AIM OF THE STUDY To exclude the contralateral neck (totally or partially) from the irradiated fields, when justified.

29 ELIGIBLE PATIENTS Eligible patients (40 patients): Early-stage HNC (T1-3N0-2b SCC oral cavity, oropharynx, hypopharynx, and larynx) Will be treated by primary RT, with or without CT Clinically and radiologically node-negative neck, at least on one side (N0-1) Not crossing the midline

30 END POINTS Feasibility and safety Regional control at 1 year Acute and late toxicity QoL

31 STUDY PROCEDURE Intensive work up for highly accurate nodal staging: 1.US-FNA, done by dedicated HN radiologist 2.CT or MRI 3.When indicated: FDG-PET, in 5-points thermoplastic mask according to standard RT protocol

32 STUDY PROCEDURE US-FNA Work up according to the IGL Lateralized T not crossing midline MRI/CT PET, when indicated Yes No Eligible Not eligible EUA and intra-tumoral injection of 99mTc followed by SPECT BNI Contralateral tracer accumulation? Yes No Elective RT to the IL neck and the level CL with +SN Elective RT only to the IL neck

33 CURRENT STATUS SUSPECT (IPSILATERAL DRAINAGE SPECT) Excluded N=7 Included N=41 No CL SN N=2 laser Treated accordingly N=31 Level I 6% Level II 70% Level III 60% Level IV 45% Level V 12% Level VI 3% RP 3%

34 CURRENT STATUS SUSPECT (CONTRALATERAL DRAINAGE SPECT) Excluded N=7 Included N=41 No CL SN N=2 laser Treated accordingly N=31 OPC N=21 OCC N=2 HPC N=3 LC N=5 CL SN N=4 (L II, III) CL SN N=1 (L II) CL SN N=1 (L III) CL SN N=2 (L IV) CL SN Total=8/33 (24.2%)

35 VERY PRELIMINARY RESULTS (MATCH-PAIRED ANALYSIS 25 UNI X 25 BNI) Tumor site N-stage T-stage HPV-status Chemo UNI BNI 5 0

36 VERY PRELIMINARY RESULTS (MATCH-PAIRED ANALYSIS 25 UNI X 25 BNI) Chi square p= Chi square p= Chi square p=0.004 UNI BNI 0

37 DANK VOOR UW AANDACHT