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Bakgrund: Det är idag en väl etablerad sanning att bröstbevarande operation medefterföljande helbröstbestrålning är ett patientsäkert alternativ till att operera bort hela bröstet(mastektomi) vid primär bröstcancer. Det är fortfarande rutin att föreslå strålbehandling tillalla kvinnor som genomgått bröstbevarande operation även om vi vet att nyttan avstrålbehandlingen är individuell. Medan nyttan varierar är biverkningarna mera generella. Devanligaste biverkningarna drabbar hjärtat och lungorna. För att minimera biverkningarna kanman antingen bara stråla en del av bröstet (PBI) eller helt avstå strålbehandling.Syfte: Syftet med denna studie var att undersöka och se om äldre kvinnor opererade medbröstbevarande operation för lågrisk bröstcancer har nytta av strålbehandling och i så fall ivilken grad.Metod: En systematisk litteraturstudie med PubMed som vald databas för att samla relevantapublicerade artiklar. Relevanta sökord som användes var; breast cancer, breast conservingsurgery, radiotherapy, low risk, omitting och partial breast irradation Resultat: Totalt inkluderades 10 artiklar efter att ha identifierat 65 abstrakt varav 21 artiklarlästes i fulltext. Studier som jämför helbröst strålbehandling mot inget visar en statistisktsignifikant ökad risk för lokalt recidiv om man avstår strålbehandling, men i absoluta tal ärskillnaden liten och försämrar inte överlevnaden. Studier som jämför delbröst mot helbröststrålbehandling visar att delbröst strålbehandling i direkt anslutning till bröstbevarandeoperation inte ökar risken för lokalt recidiv och försämrar inte överlevnaden.Slutsats: För kvinnor >45 år är PBI i direkt anslutning till bröstbevarande operation ett säkertalternativ till helbröst strålbehandling. För äldre kvinnor (>65–70 år) med hormonkänsliglågrisk bröstcancer är det ett alternativ att helt avstå strålbehandling.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第19225号 / 医博第4024号 / 新制||医||1010(附属図書館) / 32224 / 京都大学大学院医学研究科医学専攻 / (主査)教授 戸井 雅和, 教授 富樫 かおり, 教授 一山 智 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DGAM

Brachytherapy (BT) with continuous low dose rate (LDR) has been used for 100 years and is considered as the radiotherapy method able to deliver a dose in the shortest time with high efficacy and low risk of side effects. The drawbacks are need for patient isolation and radiation exposure of the staff during the treatment. Brenner and Hall published the radiobiology concept for pulsed dose rate (PDR) in 1991.  Short (10-20 minutes), hourly pulses of high dose rate (HDR) given to the same dose, with same overall treatment time will virtually simulate continuous LDR. At the same time new afterloading machine technology became available, where a single millimetre sized radiation 192Iridium source sequentially moves through the applicator in small individually timed steps. The advantages are that the radiation dose can be optimized along the applicator and with no radiation exposure of the staff and no need for patient isolation more than during the pulse. This work deals with four different aspects of PDR BT An experimental comparison of measured absorbed doses outside a left sided breast target on a body equivalent Alderson phantom was made.  Five external beam radiotherapy (EBRT) whole breast treatments to 50 Gy versus five accelerated partial breast irradiations (APBI) by PDR BT to 50 Gy were studied. The absorbed doses were measured in 67 different positions inside the body phantom by thermoluminescence dosimeters. The result shows that dose points distant to the left breast will have 1-1.4 % of the prescribed dose with no difference between EBRT and PDR BT. Organs at risk in short distance (<5 cm) to the target (such as parts of the left lung, heart muscle and the right breast) will have significantly less dose by PDR BT. In conclusion PDR BT has dosimetric advantages close to the target compared to EBRT and cannot do more damage to remote organs. PDR APBI as the adjuvant RT treatment to breast conserving surgery after early breast cancer was studied. Between 1994-2004 we treated 50 women and 51 breasts. The median age of the population was 53 (40-72) years. The cases were radically resected, unifocal T1-2N0-1M0 tumours. PDR BT was given to a dose of 50 Gy for 5 days directed to the operated sector of the breast. The median treated volume was 160 cm3, constituting in median 31 % of the breast volume. The treatment is called accelerated because total treatment time is 5 days compared to 5 weeks for EBRT. After a median follow-up of 130 months (>10 years) we noted 5 (10 %) local recurrences in the treated breast. Four of these recurrences were outside the treated volume. Three women (6 %) developed cancers in the other breast. Early side effects were mild and less than with EBRT. As late side effects we found mild to moderate local fibroses in the treated volume. A cosmetic evaluation was done by both the patient and a nurse and was found to be lower than in other published data (56 % = good to excellent). The 10 years local failure rate is similar to the result from a large Swedish randomized study on whole breast radiotherapy to 50 Gy. The study indicates that PDR BT is highly effective. A combination of EBRT (40.8 Gy) and PDR boost (35 Gy) to T1-4N0-3M0, base of tongue (BOT) cancer, treated during 1994-2007 was analyzed. The study is the first with PDR and second largest with BT worldwide. A number of 83 patients with a median age of 60 (38-82) years were included. BT was given to a mean volume of 58 ccm 2 days after the neck dissection. Median follow-up was 54 months. At 5 years we found 89 % local tumour control, 95 % neck control, 80 % disease free survival and an overall survival of 65 %. Late side effects were 13 % minor transient soft tissue necrosis and 12 % long lasting or permanent soft tissue- or osteoradio-necrosis. The results are among the best published worldwide. An extensive quality of life analysis was done on 45 patients at last follow-up and showed limited, persistent xerostomia and dysphagia. The global quality of life was rated good in 75 % of the patients. The last study presented was PDR mono-brachytherapy (55-60 Gy) to cancer of the lip (T1-3N0M0). The study included 43 patients with a median age of 74 (37-92) years. The treatment time was 5.5-6 days and the mean treated volume was 15 ccm. The median follow-up time was 54 (1-158) months. Five year Kaplan-Meier data showed, local control 94 %, disease free survival 86 % and overall survival 59 %. An early side effect was a strong radiation mucositis and dermatitis, which healed in 1 month. Late side effects were uncommon and the cosmetic appearance and the lip function were found to be normal. Our data in total and per T-stage was compared to a European survey from 1993 on 2794 patients treated by LDR BT. The results are similar and are a strong indication of equal efficacy between PDR and LDR.