- Email: [email protected]
157 The pros and cons of linked versus loose seeds
CARe 2003
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Recurrent nasopharyngeal cancer treated with fractionated stereotactic radiation therapy J. Waldron, L. Gitterman, S. Ladak, S. McKinnon, M. Heydarian, B. Cummings, A. Bayley, J. Kim, D. Payne, J. Ringash, P. Warde, B. O'Sullivan Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
The use of inflammatory serum markers as an objective measure of acute and sub-acute mucositis receiving radiation + chemotherapy for head and neck cancer I. Peon 1, E. Elliot2, I. Hodson 3, J. Sathya 3, G. Browman 3, J. Wright3 1Toronto Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada 2University of Toronto, Toronto, Ontario, Canada 3Hamilton Regional Cancer Centre, Hamilton, Ontario, Canada
Puroose: To describe the use of fractionated stereotactic radiation (FSRT) for the treatment of recurrent nasopharyngeal carcinoma (NPC). Materials and Methods: A review was conducted of 15 patients with recurrent NPC treated with FSRT between 1997 and 2002. Results: There were 7 males and 8 females, median age at recurrence: 50 years (range: 14 to 64). All patients had originally undergone curative radiation and had local and/or regional lymph node failure. Median time to recurrence was 3.5 years (range: 0.8-30). T categories at recurrence were: rT0(2), rTl(3), rT2A(1), rT2B(5),rT3(1), rT4(3). Four patients had nodal recurrence, and in two this was the only site. The median total retreatment dose was 55 Gy (range 50-60 Gy). All but one (who received 1.25 Gy bid) received once daily fractions (1.8-2.0 Gy). For 13/15 patients FSRT was the only radiation technique. Two patients were treated with a combination of conventional radiation followed by FSRT. Concurrent chemotherapy was administered to five and neeadjuvant chemotherapy (prior to FSRT) to three. Two patients with neck recurrence had surgical resection prior to FSRT. The median follow up time after recurrence was 2.1 years (range 0.6-5.1). 5/15 patients experienced progression at the primary site following FSRT. The 2 year actuarial rates of overall and disease free survival after treatment for recurrent disease were 100% and 67%. Local, nodal and distant progression-free rates at 2 years were 67%, 100% and 100% respectively. No significant late toxicity has been apparent in any patient at the time of reporting. Conclusions: FSRT at doses up to 60 Gy can be safely offered to selected patients with Iocoregionally recurrent NPC. With radiation doses > 50Gy the majority of patients remained free of local progression. 157
The pros and cons of linked versus loose seeds J. Crook Princess Margaret Hospital University of Toronto, Toronto, Ontario, Canada Puroose: The risk of seed migration through venous channels after prostate brachytherapy is minimized by using linked seeds. We report the incidence of seed migration for linked vs loose seeds, and the effect of seed type on implant quality. Materials and Methods: The prostate brachytherapy program began in 03/99. Linked seeds were introduced in 09/00. From 07/00 to 10/02, 234 implants were performed, using linked seeds for 153 and loose seeds for 81. Prostate volumes > 60 cc (20 %) had a short course of androgen deprivation to shrink the prostate. Chest x-rays and post implant dosimetry (using CT-MRI fusion) were evaluated at 30 days. Linked seeds were preferred for very small prostates < 25 cc (8% of population). Results: Seed migration to the lung occurred in 3.4 % of linked seed cases and 17.4% of loose seeds cases (p=0.002). The median number of seeds migrating was one (range 1-3). Cases with linked seeds were more likely to have had prior hormones (24% vs 11.5%, p=0.017) and smaller prostates (32.7 cc vs 37.6 cc, p<0.0001). Factors influencing implant quality determined by V100 were examined. In univariate analysis, prior hormones (p<0.0001), prostate volume at one month (p=0.0008), difference in volume from implant to 1 month (Vdiff p<0.0001), and seed type (p=0.0007) all predict implant quality. In multivariate analysis, when the effect of prostate swelling (Vdiff), and prior hormone use are controlled for, seed type remains predictive of implant quality (p=0.017) in favour of loose seeds. V100 at one month decreases with increasing prostate swelling (Vdiff) with a slope of 0.55.The rate of decrease of V100 with Vdiff is steeper with linked seeds (slope = -0.583) as compared to loose seeds (slope = -0.393). Conclusions: Linked seeds reduce seed migration to the lung, but may be associated with inferior implant quality. The effect of prostate swelling on dosimetry may be minimized by the use of loose seeds that are able to move with the expanding prostate. Further studies are underway to characterize prostate swelling and its effect on dosimetry.
Introduction: Radiation induced mucositis is one of the dose limiting toxicities in head and neck cancer (HNC) treatment. Despite this, many mucositis scoring systems exist that can be cumbersome to administer and subject to inter- and intra-observer variability. Materials and Methods: Patients receiving curative doses of radiation + chemotherapy were entered in the trial. C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR) was drawn weekly and one month post completion of RT. Mucositis and dermatitis was measured using the McMaster HNRQ symptom score, RTOG, Common Toxicity Criteria Version 2.0 (CTC V2.0). Weight loss, nutritional intake, medications including mouthwashes, gastrostomy tube use was recorded. -Results: Of the twenty patients entered, the data of 17 patients is currently available. The average age was 59 years with 16 patients staged as Ill/IV. The primary sites include nasopharynx, oropharynx, hypopharynx, oral cavity, larynx, unknown primary and skin. 16 of 17 patients received the full dose. Eleven of 17 received 7000 cGy, 4 received 6000cGy, 1 received 5000cGy and 1 patient expired during treatment. 12 patients received concurrent chemotherapy consisting mostly of daily Cisplatin 6mg/m 2. The baseline values of and CRP and ESR was elevated in 8 and 11 patients respectively. In most patients, both CRP and ESR rose throughout treatment, peaking during the final week of RT with a decline at the 1 month follow-up. 5 patients showed no rise in either CRP or ESR during treatment although only 3 showed no rise in both values. The absolute serum marker values appear to reflect the radicality of the treatment. Conclusions: Inflammatory serum markers may be a helpful objective measure ofthe degree of radiation induced mucositis experienced by patients. A minority of patients do not show elevations in inflammatory serum markers despite the presence of radiation induced mucosal inflammation. 159
Time dose fractionatien in total skin electron therapy S. Hussein Fraser Valley Cancer Centre, British Columbia Cancer Agency, Surrey, British Columbia, Canada This work reports and discusses the time-dose-fractionation (TDF) regimens currently used in Total Skin Electron Therapy (TSET) to treat mycosis fungoides. The reported regimens were obtained from a survey of TSET users, carried out in a larger context to document current practice related to physical, dosimetric and clinical aspects of TSET. Its goal was to increase awareness amongst TSET users of the many variables involved and to enumerate the commonly used practices in current use and, thereby, promote standardization. The quality of responses was excellent, both in completeness and content. A simple linear-quadratic (L-Q) model with no re-population is used to compare the relative effectiveness of the TDF regimens and analyze the data in an attempt to arrive at an optimum regimen. The results show that, although there is a considerable variation in the currentlY used regimens, a total dose of 32 Gy delivered in eight 4 Gy fractions emerges as a logical choice. The linear quadratic model affirms this conclusion.
3-5 October 2003
S39
156
158
Recurrent nasopharyngeal cancer treated with fractionated stereotactic radiation therapy J. Waldron, L. Gitterman, S. Ladak, S. McKinnon, M. Heydarian, B. Cummings, A. Bayley, J. Kim, D. Payne, J. Ringash, P. Warde, B. O'Sullivan Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada
The use of inflammatory serum markers as an objective measure of acute and sub-acute mucositis receiving radiation + chemotherapy for head and neck cancer I. Peon 1, E. Elliot2, I. Hodson 3, J. Sathya 3, G. Browman 3, J. Wright3 1Toronto Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada 2University of Toronto, Toronto, Ontario, Canada 3Hamilton Regional Cancer Centre, Hamilton, Ontario, Canada
Puroose: To describe the use of fractionated stereotactic radiation (FSRT) for the treatment of recurrent nasopharyngeal carcinoma (NPC). Materials and Methods: A review was conducted of 15 patients with recurrent NPC treated with FSRT between 1997 and 2002. Results: There were 7 males and 8 females, median age at recurrence: 50 years (range: 14 to 64). All patients had originally undergone curative radiation and had local and/or regional lymph node failure. Median time to recurrence was 3.5 years (range: 0.8-30). T categories at recurrence were: rT0(2), rTl(3), rT2A(1), rT2B(5),rT3(1), rT4(3). Four patients had nodal recurrence, and in two this was the only site. The median total retreatment dose was 55 Gy (range 50-60 Gy). All but one (who received 1.25 Gy bid) received once daily fractions (1.8-2.0 Gy). For 13/15 patients FSRT was the only radiation technique. Two patients were treated with a combination of conventional radiation followed by FSRT. Concurrent chemotherapy was administered to five and neeadjuvant chemotherapy (prior to FSRT) to three. Two patients with neck recurrence had surgical resection prior to FSRT. The median follow up time after recurrence was 2.1 years (range 0.6-5.1). 5/15 patients experienced progression at the primary site following FSRT. The 2 year actuarial rates of overall and disease free survival after treatment for recurrent disease were 100% and 67%. Local, nodal and distant progression-free rates at 2 years were 67%, 100% and 100% respectively. No significant late toxicity has been apparent in any patient at the time of reporting. Conclusions: FSRT at doses up to 60 Gy can be safely offered to selected patients with Iocoregionally recurrent NPC. With radiation doses > 50Gy the majority of patients remained free of local progression. 157
The pros and cons of linked versus loose seeds J. Crook Princess Margaret Hospital University of Toronto, Toronto, Ontario, Canada Puroose: The risk of seed migration through venous channels after prostate brachytherapy is minimized by using linked seeds. We report the incidence of seed migration for linked vs loose seeds, and the effect of seed type on implant quality. Materials and Methods: The prostate brachytherapy program began in 03/99. Linked seeds were introduced in 09/00. From 07/00 to 10/02, 234 implants were performed, using linked seeds for 153 and loose seeds for 81. Prostate volumes > 60 cc (20 %) had a short course of androgen deprivation to shrink the prostate. Chest x-rays and post implant dosimetry (using CT-MRI fusion) were evaluated at 30 days. Linked seeds were preferred for very small prostates < 25 cc (8% of population). Results: Seed migration to the lung occurred in 3.4 % of linked seed cases and 17.4% of loose seeds cases (p=0.002). The median number of seeds migrating was one (range 1-3). Cases with linked seeds were more likely to have had prior hormones (24% vs 11.5%, p=0.017) and smaller prostates (32.7 cc vs 37.6 cc, p<0.0001). Factors influencing implant quality determined by V100 were examined. In univariate analysis, prior hormones (p<0.0001), prostate volume at one month (p=0.0008), difference in volume from implant to 1 month (Vdiff p<0.0001), and seed type (p=0.0007) all predict implant quality. In multivariate analysis, when the effect of prostate swelling (Vdiff), and prior hormone use are controlled for, seed type remains predictive of implant quality (p=0.017) in favour of loose seeds. V100 at one month decreases with increasing prostate swelling (Vdiff) with a slope of 0.55.The rate of decrease of V100 with Vdiff is steeper with linked seeds (slope = -0.583) as compared to loose seeds (slope = -0.393). Conclusions: Linked seeds reduce seed migration to the lung, but may be associated with inferior implant quality. The effect of prostate swelling on dosimetry may be minimized by the use of loose seeds that are able to move with the expanding prostate. Further studies are underway to characterize prostate swelling and its effect on dosimetry.
Introduction: Radiation induced mucositis is one of the dose limiting toxicities in head and neck cancer (HNC) treatment. Despite this, many mucositis scoring systems exist that can be cumbersome to administer and subject to inter- and intra-observer variability. Materials and Methods: Patients receiving curative doses of radiation + chemotherapy were entered in the trial. C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR) was drawn weekly and one month post completion of RT. Mucositis and dermatitis was measured using the McMaster HNRQ symptom score, RTOG, Common Toxicity Criteria Version 2.0 (CTC V2.0). Weight loss, nutritional intake, medications including mouthwashes, gastrostomy tube use was recorded. -Results: Of the twenty patients entered, the data of 17 patients is currently available. The average age was 59 years with 16 patients staged as Ill/IV. The primary sites include nasopharynx, oropharynx, hypopharynx, oral cavity, larynx, unknown primary and skin. 16 of 17 patients received the full dose. Eleven of 17 received 7000 cGy, 4 received 6000cGy, 1 received 5000cGy and 1 patient expired during treatment. 12 patients received concurrent chemotherapy consisting mostly of daily Cisplatin 6mg/m 2. The baseline values of and CRP and ESR was elevated in 8 and 11 patients respectively. In most patients, both CRP and ESR rose throughout treatment, peaking during the final week of RT with a decline at the 1 month follow-up. 5 patients showed no rise in either CRP or ESR during treatment although only 3 showed no rise in both values. The absolute serum marker values appear to reflect the radicality of the treatment. Conclusions: Inflammatory serum markers may be a helpful objective measure ofthe degree of radiation induced mucositis experienced by patients. A minority of patients do not show elevations in inflammatory serum markers despite the presence of radiation induced mucosal inflammation. 159
Time dose fractionatien in total skin electron therapy S. Hussein Fraser Valley Cancer Centre, British Columbia Cancer Agency, Surrey, British Columbia, Canada This work reports and discusses the time-dose-fractionation (TDF) regimens currently used in Total Skin Electron Therapy (TSET) to treat mycosis fungoides. The reported regimens were obtained from a survey of TSET users, carried out in a larger context to document current practice related to physical, dosimetric and clinical aspects of TSET. Its goal was to increase awareness amongst TSET users of the many variables involved and to enumerate the commonly used practices in current use and, thereby, promote standardization. The quality of responses was excellent, both in completeness and content. A simple linear-quadratic (L-Q) model with no re-population is used to compare the relative effectiveness of the TDF regimens and analyze the data in an attempt to arrive at an optimum regimen. The results show that, although there is a considerable variation in the currentlY used regimens, a total dose of 32 Gy delivered in eight 4 Gy fractions emerges as a logical choice. The linear quadratic model affirms this conclusion.