1 RADIOTERAPIA EN CÁNCER CÉRVICO UTERINO DR. RAYMUNDO HERNÁNDEZ MONTES DE OCA R3 Instituto Nacional de Cancerología
3 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy China. Retrospectivo. 1992-1997. 257 pacientes. Radiation and Oncology 67 (2003) 69-76 Shang Wen Chen
4 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Radiation and Oncology 67 (2003) 69-76 Shang Wen Chen
5 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Radiation and Oncology 67 (2003) 69-76 Shang Wen Chen
6 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Radiation and Oncology 67 (2003) 69-76 Shang Wen Chen
7 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Radiation and Oncology 67 (2003) 69-76 Shang Wen Chen
8 The Adverse Affect of Treatment Prolongation in Cervical Cancer by High Dose Rate Intracavitary Brachytherapy Radiation and Oncology 67 (2003) 69-76 Shang Wen Chen
9 The Effect of Hemoglobin Level on Radiotherapy Outcomes: The Canadian Experience Seminars in Oncology Vol 28 No 1 Suppl 8 2001; 60-65 Gillian Thomas Multicéntrico. Canadá. 630 pacientes. 1989-1992.
10 The Effect of Hemoglobin Level on Radiotherapy Outcomes: The Canadian Experience Seminars in Oncology Vol 28 No 1 Suppl 8 2001; 60-65 Gillian Thomas
11 The Effect of Hemoglobin Level on Radiotherapy Outcomes: The Canadian Experience Seminars in Oncology Vol 28 No 1 Suppl 8 2001; 60-65 Gillian Thomas
12 Relationship Between Low Hemoglobin Levels and Outcomes After Treatment With Radiation or Chemoradiation in Patients with Cervical Cancer: Has the Impact of Anemia Been Overstated? Int J Radiation Oncol Biol Phys Vol 91 No 1; 196-205, 2015 Andrew J. Bishop 2454 pacientes. MDACC. 1980-2011. RT definitiva 43.2 – 45Gy. BQT 80-90Gy pto A. 702 pacientes (29%) QT concomitante.
13 SLR Central SLMD SEE
14
15 Conclusiones El tiempo de protracción disminuye la supervivencia global y el control pélvico por cada día extra en duración de tratamiento (
16 ESTADIOS CLÍNICOS TEMPRANOS
17 TRATAMIENTO DEFINITIVO Pacientes médicamente inoperables o que rechazan cirugía. Radioterapia sola. Dosis 70-80Gy a punto A. NCCN Guidelines Version 1.2016 Cervical Cancer
18 Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Lancet 1997; 350: 535-540 Fabio Landoni Aleatorizado, prospectivo. 1986 – 1991. 343 pacientes. EC Ib y IIa. Histerectomía radical tipo III Dosis Punto A 70-90Gy (mediana 76Gy).
19 Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Lancet 1997; 350: 535-540 Fabio Landoni
20 Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Lancet 1997; 350: 535-540 Fabio Landoni
21 Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Lancet 1997; 350: 535-540 Fabio Landoni
22 Randomised Study of Radical Surgery Versus Radiotherapy for Stage Ib – IIa Cervical Cancer Lancet 1997; 350: 535-540 Fabio Landoni
23 ESTADIOS CLÍNICOS TEMPRANOS Beneficios de la cirugía sobre la radioterapia. Menor tiempo de tratamiento. Preservación de la función ovárica. «Mejor función sexual». No hay riesgo de 2dos primarios. No hay toxicidad crónica. NCCN Guidelines Version 1.2016 Cervical Cancer
24 TRATAMIENTO ADYUVANTE Radioterapia (>1 riesgo intermedio). Tumor >4cm. Invasión > 1/3 al estroma cervical. Permeación linfovascular. Quimioradioterapia concomitante (riesgo alto). Ganglios positivos. Márgenes positivos. Invasión a parametrios. Rotman MZ. Gynecol Oncol 1999; 177-183 Peters WA. J Clin Oncol 2000; 18: 1606-1613
25 Preservación de la función hormonal: Transposición ovárica.
26 ENFERMEDAD AVANZADA IB2, IIA2, IIB-IVA
27 TRATAMIENTO DEFINITIVO Quimioradioterapia concomitante. Dosis 70-80Gy a punto A NCCN Guidelines Version 1.2016 Cervical Cancer
28 ENFERMEDAD AVANZADA IB2, IIA2, IIB-IVA National Cancer Institute: strong consideration should be given to the incorporation of concurrent cisplatin based chemotherapy with radiation therapy in women who require radiation therapy for treatment of cervical cancer. Gillian M Thomas. The New England Journal of Medicine 1999.
29 Riesgo relativo de muerte en pacientes tratados con QTRT y RT ESTUDIOFIGOnGRUPO CONTROLGRUPO EXPERIMENTAL RR DE MUERTE Keys (GOG 123)IB2369RTRT + CDDP0.54 Rose, Walkins (GOG 120) IIB-IVA575RT + HU RT + CDDP semanal0.61 RT + CDDP, 5FU, HU0.58 Morris (RTOG 90-01)IB2-IVA403RT campo extendidoRT + CDDP + 5FU0.52 Whitney (GOG 85)IIB-IVA388RT + HURT + CDDP + 5FU0.72 Peters (SWOG 8797)IB o IIA268RTRT + CDDP + 5FU0.50 ENFERMEDAD AVANZADA IB2, IIA2, IIB-IVA Keys HM. N Engl J Med 1999; 340: 1154-1161 Rose PG. N Engl J Med 1999; 340: 1144-1153 Morris M. N Engl J Med 1999; 340: 1137-1143 Whitney CW. J Clin Oncol 1999; 1339-1348 Peters WA. J Clin Oncol 2000: 1606-1613
30 Riesgo relativo de muerte en pacientes tratados con QTRT y RT ESTUDIOFIGOn Supervivencia global Aumento de la supervivencia Supervivencia libre de enfermedad Keys (GOG 123)IB236974% vs 83%9%63% vs 79% Rose, Walkins (GOG 120)IIB-IVA57547% vs 65%18%47% vs 67% Morris (RTOG 90-01)IB2-IVA40341% vs 67%16%40% vs 67% Whitney (GOG 85)IIB-IVA38843% vs 55%12%50% vs 60% Peters (SWOG 8797)IB o IIA26871% vs 81%10%63% vs 80% ENFERMEDAD AVANZADA IB2, IIA2, IIB-IVA Keys HM. N Engl J Med 1999; 340: 1154-1161 Rose PG. N Engl J Med 1999; 340: 1144-1153 Morris M. N Engl J Med 1999; 340: 1137-1143 Whitney CW. J Clin Oncol 1999; 1339-1348 Peters WA. J Clin Oncol 2000: 1606-1613
31 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale J Clin Oncol 26: 5802-5812, 2008 15 estudios aleatorizados. 3452 pacientes. RT vs QTRT
32 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale J Clin Oncol 26: 5802-5812, 2008
33 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale J Clin Oncol 26: 5802-5812, 2008
34 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale J Clin Oncol 26: 5802-5812, 2008
35 Reducing Uncertainties About the Effects of Chemoradiotherapy for Cervical Cancer: A systematic Review and Meta Analysis Claire Vale J Clin Oncol 26: 5802-5812, 2008
36 RADIOTERAPIA A GANGLIOS PARA AÓRTICOS
37 Prophylactic Irradiation of the Para Aortic Lymph Node Chain in Stage IIB and Bulky Stage IB Carcinoma of the Cervix, RTOG 7920 M. Rotman Int J Radiation Oncology Biol Phys Vol 19 513-521, 1990 Cobalto 60. Dosis pelvis 40- 50Gy. Dosis para aórticos 45Gy. 367 pacientes.
38 Prophylactic Irradiation of the Para Aortic Lymph Node Chain in Stage IIB and Bulky Stage IB Carcinoma of the Cervix, RTOG 7920 M. Rotman Int J Radiation Oncology Biol Phys Vol 19 513-521, 1990
39 Prophylactic Irradiation of the Para Aortic Lymph Node Chain in Stage IIB and Bulky Stage IB Carcinoma of the Cervix, RTOG 7920 M. Rotman Int J Radiation Oncology Biol Phys Vol 19 513-521, 1990
40 Pelvic Irradiation with Concurrent Chemotherapy Versus Pelvic and Para Aortic Irradiation for High Risk Cervical Cancer: An Update of RTOG 90-01 Patricia Eifel J Clin Oncol 22: 872-880, 2004 390 pacientes. Multicéntrico. Campos AP, PA, laterales opuestos. Dosis 45Gy (1.8Gy/fx).
41 Pelvic Irradiation with Concurrent Chemotherapy Versus Pelvic and Para Aortic Irradiation for High Risk Cervical Cancer: An Update of RTOG 90-01 Patricia Eifel J Clin Oncol 22: 872-880, 2004
42 Pelvic Irradiation with Concurrent Chemotherapy Versus Pelvic and Para Aortic Irradiation for High Risk Cervical Cancer: An Update of RTOG 90-01 Patricia Eifel J Clin Oncol 22: 872-880, 2004
43 TÉCNICAS DE RADIOTERAPIA
44 VOLÚMENES DE TRATAMIENTO TRATAMIENTO DEFINITIVO Enfermedad macroscópica. Parametrios. Ligamentos útero sacros. Margen vaginal (3cm). Ganglios pre sacros. Ganglios iliacos comunes, internos y externos. Ganglios obturadores. Ganglios para aórticos (nivel de los vasos renales): si hay ganglios positivos en iliaca común, para aórticos. Ganglios inguinales (invasión de tercio inferior de vagina). RADIOTERAPIA POST OPERATORIA. 3-4 cm de cúpula vaginal. Parametrios. Ganglios pre sacros. Ganglios iliacos comunes, internos y externos. Ganglios obturadores. Ganglios para aórticos (nivel de los vasos renales): si hay ganglios positivos en iliaca común, para aórticos. NCCN Guidelines Version 1.2016 Cervical Cancer
45
46
47
48
49
50
51 Dosis: 40-50Gy en fracciones de 1.8-2Gy. Boost 10-15Gy a adenopatías voluminosas no resecables y parametrios. Braquiterapia: 30-40Gy a punto A (LDR). Dosis total punto A 80-85Gy. NCCN Guidelines Version 1.2016 Cervical Cancer DOSIS RT EXTERNA
52 2005 a 2010. IIB – IIIB. 122 pacientes. 45-55Gy. IMRT for Advanced Cervical Cancer: a Comparison of Dosimetric and Clinical Outcomes with Conventional Radiotherapy Gynecologic Oncology 125 (2012) 151-157 Xue-lian Du
53
54 IMRT for Advanced Cervical Cancer: a Comparison of Dosimetric and Clinical Outcomes with Conventional Radiotherapy Gynecologic Oncology 125 (2012) 151-157 Xue-lian Du
55 IMRT for Advanced Cervical Cancer: a Comparison of Dosimetric and Clinical Outcomes with Conventional Radiotherapy Gynecologic Oncology 125 (2012) 151-157 Xue-lian Du
56 IMRT for Advanced Cervical Cancer: a Comparison of Dosimetric and Clinical Outcomes with Conventional Radiotherapy Gynecologic Oncology 125 (2012) 151-157 Xue-lian Du
57 Se usa braquiterapia intracavitaria. Aplicador de cérvix: sonda central (tándem) + cápsulas laterales (ovoides o colpostatos). Aplicador de vagina (cilindro). Fuentes: HDR: Ir 192 LDR: Cs 137 BRAQUITERAPIA American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46
58 Tasa de dosis Valor de la tasa de dosis al sitio de prescripción Tasa baja de dosis (Low Dose Rate, LDR) 0.4-2 Gy/h Tasa media de dosis (Medium Dose Rate, MDR) 2-12 Gy/h Tasa alta de dosis (High Dose Rate, HDR) >12 Gy/h BRAQUITERAPIA: CLASIFICACIÓN DE ACUERDO A LA TASA DE DOSIS American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46
59 BRAQUITERAPIA American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46
60 APLICADORES DE FLETCHER SUIT DELCOS American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46
61
62
63
64
65
66
67 BRAQUITERAPIA American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46
68
69
70
71
72
73
74
75 BRAQUITERAPIA American Brachytherapy Society Consensus Guidelines. Brachytherapy 11 (2012) 33-46
76
77
78
79 The Role of Intraoperative Radiation Therapy in the Management of Recurrent and Locally Advanced Gynecologic Cancers Olivia W. Foley Int J Gynecol Cancer 2013; 23: 9-15
80 The Role of Intraoperative Radiation Therapy in the Management of Recurrent and Locally Advanced Gynecologic Cancers Olivia W. Foley Int J Gynecol Cancer 2013; 23: 9-15
81 RECOMENDACIONES POST RT Para evitar la estenosis vaginal y sequedad de la misma (2-4 semanas después del término de RT): Relaciones sexuales. Dilatador vaginal. Humectantes/lubricantes vaginales.